Adolescent Health, Vol. I: Summary and

Policy Options

April 1991

OTA-H-468

NTIS order #PB91-197921

GPO stock #052-003-01234-1
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Adolescent Health---Volume I: Summary

and Policy Options, OTA-H-468 (Washington, DC: U.S. Government Printing Office, April

1991).

For sale by the Superintendent of Documents

U.S. Government Printing Office, Washington, DC 20402-9325

(order form can be found in the back of this report)
Foreword

Adolescence, the poet suggested, ‘ ‘is the one age [that] defeats the metaphor. ’ In many respects, such

as legal and financial dependence, adolescents are still children; in other respects, such as physical

development, they approach and then reach adult status. In part because they experience profound biological,

emotional, intellectual and social changes, adolescents as a group-and some adolescents more than

others—are uniquely vulnerable to the impact of many of the Nation’s social policies. For numerous reasons,

policymakers and the public have long struggled with the establishment of appropriate health-related policies

and programs for adolescents.

OTA’s report responds to the request of numerous Members of Congress to review the physical,

emotional, and behavioral health status of contemporary American adolescents, including adolescents in

groups who might be more likely to be in special need of health-related interventions: adolescents living in

poverty, adolescents from racial and ethnic minority groups, Native American adolescents, and adolescents in

rural areas. In addition, OTA was asked to: 1 ) identify risk and protective factors for adolescent health problems

and integrate national data in order to understand the clustering of specific adolescent problems, 2) evaluate

options in the organization of health services and technologies available to adolescents (including accessibility

and financing), 3) assess options in the conduct of national health surveys to improve collection of adolescent

health statistics, and 4) identify gaps in research on the health and behavior of adolescents.

Senator Daniel K. Inouye, Chairman of the Senate Select Committee on Indian Affairs, and Senator Nancy

Landon Kassebaum, Ranking Minority Member of the Subcommittee on Education, Arts, and Humanities of

the Senate Committee on Labor and Human Resources, were the lead requesters of OTA’s adolescent health

study. Requesters included Chairmen or Ranking Minority Members of the Senate Appropriations Committee,

the Senate Commerce, Science, and Transportation Committee, the Senate Finance Committee, the Senate

Labor and Human Resources Committee, the Senate Small Business Committee, the Senate Veterans’ Affairs

Committee, and the House Interior and Insular Affairs Committee; and the Chairman and six senatorial

members of the congressional Technology Assessment Board. A letter of support was received from the House

Select Committee on Children, Youth. and Families.

This OTA assessment is being published in three volumes: Volume I, Summary and Policy Options;

Volume 11, Background and the Effectiveness. of Selected Prevention and Treatment Services; and Volume 111.

Crosscutting Issues in the Delivery of Health and Related Services. Volumes II and 111 will be available later

in 1991. Two related reports have already been issued as part of this study (see appendix A).

This assessment was greatly assisted by an advisory panel, chaired by Felton Earls, Professor of

Behavior-al Sciences at the Harvard University School of Public Health. Michael I. Cohen, Chairman of the

Department of Pediatrics at the Albert Einstein College of Medicine in New York, served as vice chairman.

In addition, many individuals from academia, the Federal Government, the private sector, and the public

provided information and reviewed drafts of the assessment. OTA would like to especially thank Carnegie

Corporation of New York, and its operating program, the Carnegie Council on Adolescent Development, for

their generous and diverse assistance throughout the course of this assessment. Finally, the members of our

Youth Advisory Panel—a group of 21 individuals ages 10 through 19, who met often with OTA staff, with

OTA’s advisory panel, and with workshop participants-were essential to the study. These young people

provided the adolescent perspective on health concerns of importance to young people, and made valuable

suggestions for improving health services and health policy. The final responsibility for the content of the

assessment rests with OTA.

/f’/ a’rL7ydL4- ,

JOHN H. GIBBONS

,,,

Ill
Adolescent Health Advisory Panel

Felton Earls, M. D., Chair

Professor, Department of Behavioral Sciences

Harvard School of Public Health, Boston, MA

Michael I. Cohen, M. D., Vice Chair

Chairman, Department of Pediatrics

Albert Einstein College of Medicine, Montefiore Medical Center

Claire Brindis, Dr. P.H.

Center for Reproductive Health

Policy Research

Institute for Health Policy Studies

UCSF School of Medicine

San Francisco, CA

Ann W. Burgess, R. N., D. N. SC.

van Amerignen Professor of

Psychiatric Mental Health Nursing

University of Pennsylvania School of

Nursing

Philadelphia, PA

Delores L. Delaney

President

State of Virginia Parent and Teacher

Association

Virginia Beach, VA

Abigail English, J.D.

Staff Attorney

Adolescent Health Care Project

National Center for Youth Law

San Francisco, CA

Jewelle Taylor Gibbs, Ph.D.

Associate Professor

School of Social Welfare

University of California

Berkeley, CA

Michael Graf, Ph.D.

Director, Mental Health

Tanana Chief Conference, Inc.

Fairbanks, AK

David E. Hayes-Bautista, Ph.D.

Professor, School of Medicine

Director, Chicano Studies Research

Center

University of California, Los Angeles

Los Angeles, CA

Karen Hein, M.D.

Associate Professor

Division of Adolescent Medicine

Department of Pediatrics

Albert Einstein College of Medicine

Montefiore Medical Center

Bronx, NY

Bronx, NY

Charles E. Irwin, Jr., M.D.

Director

Division of Adolescent Medicine

Department of Pediatrics

School of Medicine

University of California

San Francisco, CA

Robert Johnson, M.D.

Associate Professor

Division of Adolescent Medicine

Department of Pediatrics

New Jersey Medical School

Newark, NJ

Alan Kazdin, Ph.D.

Professor

Department of Psychology

Yale University

New Haven, CT

Teresa LaFromboise, Ph.D.

Assistant Professor

Counseling Psychology and

Counselor Education

The School of Education

University of Wisconsin

Madison, WI

Mary Nell Lehnhard

Vice President

Office of Government Relations

Blue Cross & Blue Shield Association

Washington, DC

Barbara D. Matula, M.P.A.

Director

Division of Medical Assistance

Department of Human Resources

State of North Carolina

Raleigh, NC

Robert B. Millman, M.D.

Director, Adolescent Development

Program

Director, Alcohol & Substance Abuse

Service

Cornell University Medical CollegeNew York Hospital

New York, NY

Leticia Paez, M.P.A.

Associate Director

Area Health Education Center

School of Medicine

Texas Technical University

El Paso, TX

Cheryl Perry, Ph.D.

Associate Professor

Division of Epidemiology

School of Public Health

University of Minnesota

Minneapolis, MN

Anne C. Petersen, Ph.D.

Dean, College of Health & Human

Development

Pennsylvania State University

University Park, PA

Lee Etta Powell, Ph.D.

Superintendent

Cincinnati Public Schools

Cincinnati, OH

Roxanne Spillett

Director, Program Services

Boys and Girls Clubs of America

New York, NY

Edward Tetelman, J.D.

Assistant Commissioner

Intergovernmental Affairs

New Jersey Department of Human

Services

Trenton, NJ

Myron Thompson

Trustee

Bernice Pauahi Bishop Estate

Honolulu, HI

NOTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the advisory panel members.

The panel does not, how-ever, necessarily approve, disapprove, or endorse this report. OTA assumes full responsibility for the

report and the accuracy of its contents.

iv
Adolescent Health

Roger C. Herdman, Assistant Director, OTA

Health and Life Sciences Division

Clyde J. Behney, Health Program Manager

Project Staff

Denise Dougherty, Project Director

Jill Eden, Senior Analyst

Kerry B, Kemp, Analyst/Division Editor

Kelly Metcalf, Research Analystl

Kirsten Rowe, Analyst 2

Gloria Ruby, Senior Analyst

Pamela Simerly, Analyst

Andrea Solarz, Carnegie Detailee3

Urvi Thanawala, Research Assistant4

Paul Robertson. Research Assistant5

Other Staff

James Havel, Carnegie Contractor6

Charlotte Clarke, Carnegie Contractor

Elizabeth Anglarill, Work Study Student8

Helima Croft, Summer Intern9

Jennifer Hart, Summer intern’”

Administrative Staff

Virginia Cwalina, Office Administrator

Carol Ann Guntow, P.C. Specialist

Carolyn Martin, Word Processor Specialist

Eileen Murphy, P.C. Specialist

‘Until July 1990

2From October 1988 to March 1990

~From Dcccm~r 1988 to August 19~

‘$From June 1990

5From September 1990

~From ,4pn] to September 1990

7From kl~y to August 199~

~From November 1989 to May 1990

Wrom May 1990 to August 1990

l~From June 1988 to August 1988
Contractors

LaRue Allen, Ph. D., University of Maryland and Christina Mitchell, Ph. D., New York University*

Trina Anglin, M. D., Ph. D., Cleveland Metropolitan General Hospital*

Lois Bergeisen, Gaithersburg, MD

Barbara Bums, Ph. D., Duke University,

Carl A. Taube, Ph.D.(deceased 9/28/89), Johns Hopkins University,

and John E. Taube, University of Maryland*

Paul Casamassimo, D. D, S., M. S., Children’s Hospital, Columbus, OH

Johanna Dwyer, D.Sc., R. D., New England Medical Center Hospital, and

Carol N. Meredith, University of California at Davis

James Emshoff, Ph.D. and Ronnie Margolin, Georgia State University*

Mathea Falco, J. D., New York, NY

Ronald A. Feldman, Ph. D., Columbia University

Michelle Fine, Ph. D., University of Pennsylvania

James Garbarino, Ph. D., Erikson Institute

Josephine Gittler, J, D., Mary Quigley-Rick, J.D,, and Michael J. Saks, Ph. D., University of Iowa

Robert Guntow, Hyattsville, MD

Angela Holder, LL.M., Yale University*

Jonathan Klein, M. D., M. P. H., Milton Kotelchuck, Ph. D., and

Gordon H. DeFriese, Ph. D., University of North Carolina at Chapel Hill*

Barry Krisberg, Ph. D., National Council on Crime and Delinquency*

Richard Kronick, San Diego, CA*

Spero Manson, Ph. D., University of Colorado

Margaret McManus, M. H. S., Harriette Fox, M. S. W., Paul Newacheck, D. P. H., Lori Wicks,

and Rebecca Kelly, McManus Health Policy, Inc.

Gary B. Melton, Ph.D. and Lois B. Oberlander, M.A,,

University of Nebraska-Lincoln

Scott Menard, Ph. D., University of Colorado

Larry Mi’ike, M. D., J. D., University of Hawaii*

Edward P. Mulvey, Ph. D., Michael A. Arthur, M. A., and N. Dickson Reppucci, Ph. D.,

University of Pittsburgh

D. Wayne Osgood, Ph. D., and Janet K. Wilson, University of Nebraska-Lincoln*

Carol Runyan, M. P. H., Ph. D., Elizabeth A. Gerken, M. S. P. H., and

Laura S. Sadowski, M. D., M, P. H., University of North Carolina

Stanley Sue, Ph. D., University of California, Los Angeles, and

Nolan Zane, University of California at Santa Barbara*

Dalmas A. Taylor, Ph. D., Wayne State University, and

Phyllis A. Katz, Ph. D., Institute for Research on Social Problems*

H, Rutherford Tumbull, Esq., J. D., LL.M. and Lisa Dorrill, M. A.,

University of Kansas

Robert Valdez, Ph. D., University of California, Los Angeles*

Margaret West, M. S. W., Ph.D. and Sally N. Stuart, M. S. W.,

University of Washington*

“Supported by Carnegie Corporation of New York and the Carnegie Council on Adolescent Development.

vi
Volume I

SUMMARY AND POLICY OPTIONS

Thirteen’s anomalous--not that, not this:

Not folded bud, or wave that laps a shore,

Or moth proverbial from the chrysalis.

Is the one age defeats the metaphor.

Is not a town, like childhood. strongly walled

But easily surrounded; is no city.

Nor, quitted once, can it be quite recalled——

Not even with pity.

—Phyllis McGinley, ‘ ‘Portrait of a Girl With

a Comic Book”

Excerpt from ‘ ‘Portrait of a Girl with a Comic Book’ copyright [952 by PhyllIs McGinlcy, from TIMES THREE by Phyllis Mc( ;Inky

Reprinted by Permlsslon of Vlklng Penguin. a dlvlsion of Pcnguln Books [JSA Inc.
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Scope of the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Organization of the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Major Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Are American Adolescents Healthy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Which Adolescents Experience the Worst Problems? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Age Differences in Selected Adolescent Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Gender Differences in Selected Adolescent Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Racial, Ethnic, and Socioeconomic Status Differences in Selected Adolescent Health Problems. . 19

other Factors Associated With Differences in Adolescent Health Problems . . . . . . . . . . . . . . . . . . . 22

What Causes Adolescent Health Problems? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

What Should Be Done To Prevent and Treat Adolescent Health Problems? . . . . . . . . . . . . . . . . . . . . . . 24

Prevention of Adolescent Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Treatment of Adolescent Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

What IS the Federal Government’s Role in Improving Adolescent Health? . . . . . . . . . . . . . . . . . . . . . . 32

(1. S. Executive Branch Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Congressional Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Major Policy Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

A New Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Major Option 1: Congress Could Take Steps To Improve Adolescents’ Access to Appropriate Health

and Related Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Strategy 1 -1: Congress Could Support the Development of Centers That Provide Comprehensive

and Accessible Services Specifically for Adolescents in Schools and/or Communities . . . . . . . . 49

Strategy 1-2: Congress Could Take Steps To Improve Adolescents’ Financial Access to

Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Strategy 1-3: Congress Could Take Steps To Improve Adolescents’ Legal Access to

Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Strategy 1 -4: Congress Could Increase Support for Training of Health Care Providers Who

Work With Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Strategy 1-5: Congress Could Take Steps To Empower Adolescents To Gain Access to

Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Major Option 2: Congress Could Take Steps To Restructure and Invigorate the Federal Governmemnt's

Efforts To Improve Adolescents’ Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Strategy 2-1: Congress Could Create a Linus for a Strong Federal Role in Addressing Adolcscent

 Health Issues ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Strategy 2-2: Congress Could Encourage the U.S. Executive Branch To Invigorate

Traditional Federal Activities in Program Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Strategy 2-3: Congress Could Encourage the U.S. Executive Branch To Invigorate

Tradition] Federal Activities in Research on Adolescent Development . . . . . . . . . . . . . . . . . . . . . 72

Strategy 2-4: Congress Could Encourage the U.S. Executive Branch To Invigorate

Traditional Federal Activities in Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Strategy 2-5: Congress Could Create a Locus for a Strong Federal Role in Addressing Adolescent

Health Issues and lnvigorate Traditional Federal Activities in Program Development, Research,

and Data Collect ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Major Option 3: Congress Could Support Efforts To Improve Environments for Adolescents . . . . . . 76

Strategy 3-1: Congress Could Take Steps To Increase Support to Families of Adolescents . . . . . . 78

Strategy 3-2: Congress Could Take Steps To Support Additional Limitations on Adolescents’

Access to Firearms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Strategy 3-3: Congress Could Support the Expansion of Appropriate Recreational Opportunities

for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Strategy 3-4: Congress Could Monitor the Effects on Adolescents of the Implementation of the

National and Community Service Act of 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Summary of Major Policy Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Specific Findings and Policy Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

The Conceptualization of Adolescent Health (ch. 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Parents’ and Families’ Influence on Adolescent Health (ch. 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

ix
Page

Schools and Discretionary Time (ch. 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Prevention and Services Related to Selected Adolescent Health Concerns (chs. 5 through 14) . . . . . 87

Accidental lnjuries (ch.5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Chronic Physical Illnesses (ch. 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Nutrition and Fitness Problems (ch. 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Dental and Oral Health Problems (ch. 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

AIDS and Other Sexually Transmitted Diseases (ch.9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Pregnancy and Parenting (ch. 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Mental Health Problems (ch. 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Alcohol, Tobacco, and Drug Abuse (ch. 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Delinquency (ch. 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Hopelessness (ch. 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Services to

Adolescents (ch. 15) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Problems in Adolescents’ Financial Access to Health Services (ch. 16) . . . . . . . . . . . . . . . . . . . . . . . . . 110

Consent and Confidentiality Issues (ch. 17) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Issues in the Delivery of Services to Special Groups of Adolescents (ch. 18) . . . . . . . . . . . . . . . . . . . . 113

Poor Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Racial and Ethnic Minority Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Rural Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

The Role of Federal Agencies in Adolescent Health (ch. 19) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Barriers and Opportunities to Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Barriers to Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Federal Budget Deficit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Limitations of Prevailing Approaches to Program Design and Evaluation . . . . . . . . . . . . . . . . . . . . . 120

Opportunities To Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Renewed Attention to Adolescent Health Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Concerns About the Changing Nature of the Workforce and the Country’s Economic Future . . . . 121

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Appendix A. Method of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Appendix B. Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

Appendix C. Issues Related to the Lack of Information About Adolescent Health and Health and

Related Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Appendix D. Glossary of Abbreviations and Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Boxes

Box Page

A. Issues of Definition in the Assessment of Adolescent Heath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

B. Economic Costs of Selected Adolescent Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

C. Key Groups’ Recommendations on Health Education for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . 26

D. Healthy People 2000 Service and Protection Objectives That Pertain to Adolescents . . . . . . . . . . . . . 77

Figures

Figure Page

I. Growth Spurts During Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2. Overall Death Rates Among the U.S Population, by Five-Year Age Groups, 1987 . . . . . . . . . . . . . . . . . 7

3. Death Rates Among U.S. Adolescents Ages 10 to 19, by External Causes of Death, 1987 . . . . . . . . . . 8

4. Trends in Death Rates for the Five Leading Causes of Death Among U.S. Adolescents

Ages 10 to 14 and Ages 15 to 19, 1970-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

S. High School Dropout Rates in the United States, 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

6. U.S. Adolescents With HIV Infection or Other Sexually Transmitted Diseases (STDs):

National and Local Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
. .

Figure Page

7. Overview of U.S. Adolescent Pregnancy and Parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

8. Overview of U.S. Adolescents’ Use of Alcohol, Cigarettes, and Illicit Drugs, 1988 . . . . . . . . . . . . . . . . 15

9. Victimization Rates for Rape, Robbery, and Assault, by Age and Sex, 1988 . . . . . . . . . . . . . . . . . . . . . . . 16

10. Percent Mortality Due to Seven Leading Causes of Death for Black and White U.S. Adolescents

Ages 10 to 14 and 15 to 1911987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

11. Number of U.S. Adolescents Ages 10 to 18 and Number Living in Poor or Near-Poor Families,

by Race and Ethnicity, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

12. Use of Illicit Drugs by Different Adolescent Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

13, Estimated Adolescent-Specific Expenditures by U.S. Executive Branch Agencies Responding to

OTA’s 1989 Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

14. Birth Rates, Abortion Rates, Miscarriage Rates, and Pregnancy Rates Among Females

Ages 15 to 19 in 11 Countries, 1983 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

15. Trends in Sexual Experience Rates and Pregnancy Rates Among U.S. Females

Ages 15 to 19 and Trends in Pregnancy Rates Among Sexually Experienced U.S. Females

Ages 15 to 19, 1970 -88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

16. Trends in Illicit Drug Use by High School Seniors, 1975 -89, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....101

17. Trends in Arrest Rates for Serious Property Offenses and Serious Violent Offenses by Persons

Under Age 18, 1%5-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...............103

18. Trends in Arrest Rates for Aggravated Assault and Murder and Nonnegligent Manslaughter

by Persons Age 18 and Under, 1965-88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ...104

19. Distribution of Juveniles in Custody in Public Juvenile Facilities, by Racial and

Ethnic Group, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......................,..,.......105

20. Visits to Private office-Based Physicians by U.S. Citizens, All Ages Combined and

U.S. Adolescents Ages 10 to 18, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ........107

21. Distribution of visits to Private Office-Based Physicians by U.S. Adolescents

Ages 10 to 18, by Physician Specialty, 1985 . . . . . . . . . . . . . . . . . . . . . . . ................................107

22. Socioeconomic Status of U.S. Adolescents Ages 10 to 18, by Family Income as a Percent of the

Federal Poverty Level, 1987 . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. ~. . . . . . . . . . . . . . . . . . . . .. .,...............113

23. Family Incomes as a Percent of the Federal Poverty Level, by U.S. Adolescents’

Living Arrangements, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ........114

24. Family Incomes as a percent of the Federal Poverty Level, by U.S. Adolescents’ Race/Ethnicity.

1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ...116

25. Changes and Projected Changes in the Number of Dependents per loo persons of

Working Age, 1960 to 2040 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................122

26. projected Changes in the Racial and Ethnic Makeup of the U.S. Population

Under Age 18, l982 to 2080 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,., .. ..... ..............122

27. Protected Changes in the Racial, Ethnic, and Gender Makeup of the U.S. Labor Force,

1988 to 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........123

Tab/es

Table Page

1. Major Problems That Affect U.S. Adolescents’ Access to Health and Related Services . . . . . . . . . . 28

2. Primary unctions of U.S. Executive Branch Agencies With a Role in Adolescent Health ...,.... 33

3. Congressional Committees With a Role in Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

4. Summary of Three Major Policy Options Related to U,S. Adolescents’ Health . . . . . . . . . . . . . . . . . . 44

5. Strategies for Major Option 1: Congress Could Take Steps To Improve

Adolescents’ Access to Appropriate Health and Related Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

6. Strategies for Major Option 2: Congress Could Take Steps To Restructure and Invigorate

the Federal Government’s Efforts To Improve Adolescents’ Health, . . . . . . . . . . . . . . . . . . . . . . . . . . 66

7. Promising or Neglected Areas of Adolescent Health Promotion, Problem

Prevention, and Treatment: Examples of Program Development Needs . . . . . . . . . . . . . . . . . . . . . . . . 70

8. Strategies for Major Option 3: Congress Could Support Efforts To Improve

Adolescents’ Environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

9. Specific Options Related to Conceptualizations of Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . 84

10. Specific Options Related Parents’ and Families’ Influence on Adolescent Health . . . . . . . . . . . . . . . . 86

11. Specific Options Related to Schools and Discretionary Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Table Page

12. Specific Options Related to Accidental Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

13. Specific Options Related to Chronic Physical Illnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

14. Specific Options Related to Nutrition and Fitness Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

15, Specific Options Related to Dental and Oral Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

16. Specific Options Related to AIDS/HIV Infection and Other Sexually Transmitted Diseases . . . . . . 94

17. Specific Options Related to Pregnancy and Parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

18. Specific Options Related to Mental Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

19. Specific Options Related to Alcohol, Tobacco, and Drug Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

20. Specific Options Related to Delinquency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

21. Specific Options Related to Hopelessness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

22.Specifications Related to the Delivery of primary and Comprehensive Health Services to

Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

23. Specific Options Related to Problems in Adolescents’ Financial Access to Health Services . . . . . . 112

24. Specific Captions Related to Concerns About Consent and Confidentiality in Adolescent

Health Care Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

25. Specific Options Related to the Delivery of Services to Poor Adolescents, Racial and

Ethnic Minority Adolescents, and Rural Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

26, Specific Options Related to the Role of Federal Agencies in Adolescent Health . . . . . . . . . . . . . . . . . 118
SUMMARY AND POLICY OPTIONS

Introduction

Adolescents are commonly regarded as among the

healthiest of Americans, and those least in need of

health services. ’ Perhaps as a consequence, adolescent health has not been a national priority. Yet

OTA’s analysis, requested by numerous members of

Congress, 2 suggests that perhaps one out of five of

today’s 31 million adolescents (245) have at least

one serious health problem.3 Even more disturbing,

U.S. adolescents often face formidable barriers in

trying to obtain basic health care.

Particularly at risk are those adolescents who are

both poor and members of racial or ethnic minority

groups, because they are most likely to be without

the necessary safety nets that help many adolescents

through the second decade of life. But today’s white,

middle-class adolescents are also at high risk of

developing problems and not having access to

needed health services and other sources of support.

Unique income, insurance, informational, legal,

physical, and social-psychological barriers all can

interfere with the development of appropriate health

promotion, problem prevention, treatment, and environmental support strategies for adolescents.

Today’s adolescents are America’s future workforce, and OTA’s analysis of American adolescents’

health needs suggests that changes in the Nation’s

approach to adolescent health would be well worth

making. Three major options that OTA believes

Congress

4 may want to consider are:

●

●

●

improving U.S. adolescents’ access to health

services,

restructuring and invigorating Federal efforts to improve adolescent health, and

improving adolescents> environments.

Adjustments in these areas would both signal and

hasten a needed sea-change in other aspects of the

Photo credit: Education Week

Adolescents are commonly regarded as the healthiest of

Americans, yet OTA’s analysis suggests that

adolescents do have health problems and

problems gaining access to services.

Nation’s approach to adolescent health, in particular, the development of a more sympathetic,

supportive environment for adolescents.

OTA’s analysis suggests, however, that no matter

how worthwhile changes to the Nation’s approach to

adolescents can be, the changes will not all be easy

to make. Some approaches to the prevention and

treatment of the health problems of adolescents are

relatively straightforward, although they may require considerable effort and increases in funding at

a time when resources seem especially scarce.

Unfortunately, though, other solutions may be

difficult to implement. The reasons are themselves

complex but primarily include shortcomings in the

knowledge base; the fact that the beneficiaries of

change would be adolescents; and intense ideological differences within the United States on issues of

importance to adolescents. Further, the relationship

between adolescents and their parents is complicated, in that at the same time the relationship should

be preserved and enhanced, the health needs of some

adolescents may conflict with their parents’ right to

exert parental authority and control.

1A Pml,ious OTA re,po~, Healthy Children: Investing in the Fufure, examined several hca!th issues related to prenatal care, lnf~ts, ~d yOUIIg children

(224).

Congressional requesters of OTA’s Adolescent Healti Report, with current committee chair or ranking minority assignments, are listed in app. A.

“Method of the Study. ”

3Ha]th problems were dcfin~ broadly in this Report (see below). Examples of serious health problems and their prevalence among U.S. adolescents

are presented below and in app. B, ‘ ‘Burden of Health Problems Among U.S. Adolescents, ’ in Vol. H1.

‘@TA is mandated to provide advice to the U.S. Congress; thus, the focus of this Report is on the role of the Federal Government.

-1-1-
I-2 . Adolescent Health-Volume I

Scope of the Report

This Report, requested by numerous members of

Congress, reviews the physical, emotional, and

behavioral health status of contemporary American

adolescents, including adolescents in groups considered to be in special need: adolescents living in

poverty, adolescents from racial and ethnic minority

groups and Native American adolescents, and adolescents in rural areas. In addition, it identifies risk

and protective factors for adolescent health problems and integrates national data in order to understand the clustering of specific adolescent problems.

It also evaluates options in the organization of health

services and technologies available to adolescents

(including accessibility and financing), assesses

options in the conduct of national health surveys to

improve collection of adolescent health statistics,

and identifies gaps in research on the health and

behavior of adolescents.

What is adolescent health? There is no easy

answer to this question, and OTA’s analysis was

plagued throughout by issues of problem definition

(see box A). How adolescent health and adolescent

health problems are defined (e.g., broadly or narrowly, in biomedical, behavioral, or subjective

terms) and who defines them (e.g., legislators, health

providers, adolescents) have implications for assessing the extent of adolescent health problems in the

population, and whether one takes an approach that

is oriented to the promotion of well-being, or the

prevention or treatment of problems. The definition

of adolescent health also has implications for the

assignment of responsibility for designing appropriate solutions to problems.

OTA did not definitively define health for adolescents, but generally considered adolescent health in

broad terms. It has long been apparent that adolescent health in particular involves much more than

the absence of physical disease (93). The majority of

adolescents who die, for example, die not from

physical diseases but from injuries due to motor

vehicle accidents, suicide, or homicide. Some of

these, and other, adolescent health problems stem

from involvement in risk-taking behaviors (e.g.,

driving under the influence of alcohol, engaging in

unprotected sexual activity) to which adolescents

are sometimes prone. 5 Adolescent health is also

affected by family and school influences and various

other social and environmental factors. Thus, a

broad definition of adolescent health could include

aspects of the most traditional definitions of health

(i.e., the presence or absence of physical disease and

disability); adolescent problem behaviors (e.g., delinquency, drug use, sex); positive components of

health (e.g., social competence); health and wellbeing from the perspectives of adolescents themselves (e.g., perceived quality of life); and social

influences on health (e.g., families, schools, communities, policies).

For a variety of reasons, OTA focused its analysis

of adolescent health on adolescents ages 10 through

18. Definitions of adolescence vary, and many

observers agree that a definition based on age alone

is not sufficient because of significant individual

variation in the processes of adolescent development.

6 OTA decided to focus on 10- through

18-year-olds, because by the age of 10, many

individuals have begun puberty. At the age of 18, the

majority of adolescents (though certainly not all) are

still in high school and are more or less emotionally,

financially, or otherwise dependent on their parents. 7 The fact of high school graduation or legally

becoming an adult creates a whole new set of

contingencies and opportunities for addressing

health issues. OTA felt that attempting to address

s~ole~cence is ~ldely believed t. & a s~ge during which one is more prone to take risks than at other age leVelS (73). However, two recent ~views

of empirical evidence on risk-taking have found mixed results regarding the degree to which adolescents take more risks than do individuals at other

age levels (73, 125). Michael Males’ analysis of incidence rates for behaviorally related health outcomes for the period 1950 to 1985 found, for example,

higher rates of violent death (except for motor vehicle deaths), and higher rates of unwed pregnancy among adutts ages 20 to 44 than among adolescents

ages 15 to 19 (125). Furby and Beyth-Marom remark upon the dearth of research on adolescent risk-taking from a cognitive-developmental perspective,

and also question whether societal concern is with adolescent ‘‘risk taking per se, or with the particular activities in which [adolescents] choose to engage

[e.g., sex; alcohol, tobacco, and drug use; driving under the influence]” (125); Males concludes that “youth do indeed act like their parents’ and society’s

children’ (125). Irwin offers a related perspective, suggesting that adolescents’ behaviors and health outcomes can be viewed as just beginning to

resemble those of their adult contemporaries (94).

6See ch. 2, “What Is Adolescent Health?” in Vol. Il.

7cWently, tic age ofmajon~ (me age at which individuals ~ Considerd ~ults) is set at age 18 in every Sbte but AIMka, NebraskA ad Wyoming,

where the age is 19. As discussed in ch. 17, ‘‘Consent and Confidentiality in Adolescent Health Care Decisionmaking, ’ in Vol. III, some minors (e.g.,

emancipated minors and other minors on whom States have conferred special rights) have rights that are normally reserved for adults. On the other hand,

individuals who have reached the age of mjority are subject to some age-related restrictions on their behavior. In all States, for example, it is illegat

to purchase beverage alcohol for one’s own use until age 21.
Summary and Policy Options . /-3

Box A—Issues of Definition in the Assessment of Adolescent Health

Although analyses by OTA and others certainly suggest a need for attention to the health of U.S.

adolescents, it is important to note that what is meant by adolescent health is still not all that clear (93,143).

Consideration of the way the health of adolescents is conceptualized is important, because such conceptions

have significant consequences for:

. judgments about how healthy adolescents are;

• judgments about which adolescent health problems are most important;

. judgments about what health-related policies are justified and

. decisions about the development and support of measures of health and health services utilization that are

in turn used to help judge the need for changes in services and policies.

Attempts to define adolescent health can be informed by appraisals of the developmental goals of the

adolescent period as well as by notions of what life is like during adolescence. Examination of these issues

leads to support for a broad definition of adolescent health. However, existing quantitative assessments of

adolescent health, and even attempts to further develop definitions of adolescent health have not caught up with

the conclusion that adolescent health needs to be thought of broadly (93,143). Additional issues relating to the

definition of adolescent health include who defines health and health problems, the social context of the

definition of health problems, difficulties in operationalizing well-being, and the potential consequences

of broadening the definition of adolescent health.

What Is Adolescence?

Adolescence cart be viewed, as can all other periods of human development, in terms of the execution of

an individual’s ‘‘developmental tasks”l

as well as in terms of an individual’s contemporaneous sense of

well-being. Thus, an important consideration in framing a definition of adolescent health is the matter of the

developmental goals of the adolescent period, socially defined. Although one difficulty in gaining the attention

of policymakers for some adolescent health concerns is that adolescence is often viewed solely as a transitional

period between childhood and adulthood (93), it would be almost impossible to construct a new definition of

adolescent health without considering what it is an individual should be like as she or he leaves adolescence.

The elements of a healthy and successful young adult human being are, of course, open to question, but

in late 20th century United States, one could hardly argue with the notion that, as individuals reach

adulthood, they should optimally be beginning to be productive, contributing members of society, who

meet commitments to families and friends and the responsibilities of citizenship (28). Further, even as

they meet essential social obligations, life should generally be satisfying, and individuals should have

the potential to continue to grow.

But as important as the goals of the developmental period called adolescence are, the adolescent period

in the contemporary United States can itself encompass one-seventh of the life span or more.2 So, an

important issue to consider, in addition to considerations of health related to the transition into

adulthood, is the parameters of health during adolescence. 3

Do Existing Definitions of Health and Indicators of Health Status

Correspond to an Optimal Definition of Adolescent Health?

For quite some time, the concept of health was limited to physical health (251). This view was

understandable as long as the causes of death and disability were largely physical in nature (251,288). An

l~e tem “developrnen~” and tie notion that there are “stages” of developmen~ each with developmental “tMks,” shodd b view~

with caution. I..evels of human development have been somewhat arbitrarily freed according to chronological ages (e.g., infancy, childhood,

adolescence, young adulthood). Development ‘‘tasks” are skills, levels of achievement, and social adjustment considered important at certain

ages for the successful ad@rnent of the individual, and for the individual to progress to the next “stage.”

z~~~ cm &gin at age 10 or mm somw~t ~ller ad, ~au~ of educatio~ gods or o~er social f~ton, some individuals delay

their entry into adult roles until their mid-twenties (62). (As noted elsewhere, however, OTA’s assessment focused on the period ages 10 through

18.)

3As diSCUSSd e~ewhere in thk Repoz the formerly popular notion that for adolescents to be normal is abnormal h ~n ~X~it~

(see, e.g., 62). Such notions led to the view that poor heal@ in particular, poor mentat healti odd behavior, and subjective distress, were to be

expected during adolescence.

Continued on next page
I-4 . Adolescent Health-Volume I

Box A—Issues of Definition in the Assessment of Adolescent Health-Continued

advance in the conceptualization of health was made when individuals’ engagement in health-related

individual behaviors were added to physical problems as indicators of the health status of the population

(143,251 ). This change was made in recognition of the fact that many persistent physical health problems (e.g.,

heart disease, lung cancer, and the trauma resulting from “accidental” injuries) were associated, at least in part,

with factors related to behaviors apparently freely chosen (251,289). 4

In no sense, however, have widely published measures of health status approached the increasingly

accepted World Health Organization definition that health should be defined as “complete physical, mental,

and social well-being” (86). In the United States, the health status of the population is still measured primarily

in terms of mortality or is inferred from the extent to which individuals seek care from physicians (289).56

Many observers agree that traditional measures of health status such as overall mortality rates and utilization

of physicians are inappropriate to assessing the health of adolescents. Most of the health problems experienced

by adolescents do not result in death, at least not immediately (96,107),7 and, as discussed at length in this

Report, there are reasons other than the absence of health problems for adolescents not to use the mainstream

health services system.8 One of the reasons adolescents may not use the mainstream health services system

is that it is oriented primarily toward the treatment of physical disease; mental, behavioral, and social problems

tend to be addressed by other systems of care.9 A broader view of health-emphasizing mental and social,

as well as physical, aspects and a sense of well-being as well as the absence of problems-can be said

to fit the period of adolescence much better than does a narrow focus on the absence of physical health

problems. 10

Other Issues

Other issues affecting the way adolescent health is defined include the extent of adolescent participation

in defining health and health problems, broader social influences on defining adolescent problems, difficulties

with operationalizing well-being, and the impact on existing systems of redefining health.

As a generally (legally) powerless group, adolescents have very little say in the way health and health

problems are defined and measured, but the way that adolescent health and health problems are defined and

measured greatly influences adolescents’ lives. The evidence is scarce on this point but adolescents have been

found to see discrepancies between issues of concern to them and issues likely to be discussed by health care

providers and others who have the potential to affect adolescent health and make referrals to health care

services (89,126,193). Clearly, if there is disagreement on what adolescent health and health problems are,

there is likely to be disagreement on appropriate approaches to promoting health and to addressing problems.

It is further important to recognize that some things that are regarded as adolescent health problems are

problems only in the context of the contemporary social environment. Possibly, for example, dropping out of

% presence of a mental health problem h also considered an aspect of health (143), although Fedend overviews of the health status

of the population rarely include information on mental health status measures (e.g., 289). Further, many adolescen t mental disorders are defined

in behavioral terms (9).

5Relatively recent efforts to make measures of mortality more mlt?v~t to J’OUngeX pOpU.btiOIIS, such ~ es~ks of Pm mature mortality

(e.g., years of potential life lost (289)), constitute an important advance, however.

6Additio~isWes con~rning the information available about adolescent health status, even using widely accepted indicators w -mm%

are discussed in app. C, “Issues Related to the Lack of Information About Adolescent Health and Related Services.”

71XI tie 1OWW telyn, life expectanw maybe shortened by use of alcohol, tobacco, and drugs, tiother Muwiors d-~olmc~e.

%&MS Volme and chs. 15, “MajorIssues Pert@ing to the Delivery of Primary and Comprehensive Health Services to Adolescents,”

16, “Financial Acxess to HeaIth Services,” 17, “Consent and Cordldentiality in Adolescent Heakh Care ~isiom,” @18, C$ISSu~ in

the Delivery of Services to Selected Groups of Adokscents,’ in Vol. ID.

9S= vol. ~ of ~s Repofi, “B~k~o~ ~~Eff~tive~ss of s~~t~ ~~tion~ Tr~~ent Swic@.” Even dental and nutrition

services, which apply to the body, are separate from the so-called primary health care system.

IOAl~u~ adolexa~ do ~ve physic~ h~~ p~blems, ~q MC re&tive/y fIW of @ kinds of life-threatening physical (&W&WX tht

affect the very young or very old.
Summary and Policy Options . I-5

high school (or not going onto college) might not be so terrible for some adolescents if jobs at living wages

or other alternatives were available (330) or if academic paths were more flexible. The social environment is

the product of longstanding cultural and philosophical roots in this country that are not about to be changed

in a wholesale manner (25), but it is important to recognize the social environment’s impact on the way

adolescent health problems are defined.

A further social dilemma concerns operationalizing the concept of “complete. . well-being” (86). Although

broadly acceptable definitions of complete well-being could be socially constructed, they would be difficult to

devise because to a large extent complete well-being is inherently a subjective notion.

Finally, it is important to note certain potential barriers to changes in the way adolescent health is

conceptualized. One is that adopting broader definitions of health could lead to either a broadening of what is

considered the health care system (e.g., to include the mental health, substance abuse, social services, nutrition,

recreation and fitness, and other systems of care for adolescents) or the broadening of skills of medical providers.

Enlarging the definition of the health care system might be expected to upset current hierarchical arrangements

among caregivers. On the other hand, given the range of expertise required to address all the health needs of

adolescents under an expanded conceptualization of adolescent health, multiplying the number of skills required

of a single type of practitioner seems unrealistic.

A second potential effect of expanding the definition of health for adolescents is related to the expanded notion

of a health care system and is important because it can have cost implications. If a broader definition of health is

adopted, the range of “health-related problems” amenable to possible intervention (i.e., health services) becomes

larger. If art intervention is defined as a health-related service, it becomes a potential target for the commitment of

public funds (e.g., under Medicaid) or private third-party reimbursement. Such a consequence is not inevitable, but

it is worth considering as an explanation for why an expanded definition of adolescent health may be resisted.

Conclusions

Definitional issues in adolescent health will undoubtedly persist as the findings of OTA’s report, and

others related to adolescent health (e.g., 6,29,51,52,137,148,150, 152, 153), are considered by local and national

policymakers, parents, researchers, and adolescents themselves. Further, many of these issues are relevant to

populations other than adolescents. However, a broader definition of health is especially important for

adolescents because adolescence is a critical transitional period (62,84) and because narrower definitions of

health can lead to the neglect of important health issues during adolescence.ll

New constructs and theoretical perspectives, OTA believes, should probably include consideration of the

specific individual involved, the specific health concern, and the individual’s social environment. In addition

to traditional measures of physical health and the newer behavioral measures, a broad range of indicators of

optimal functional status (emotional and social, including perceived quality of life) should be considered by

researchers, health care providers, and policymakers.

A broad definition of health would therefore include aspects of the most traditional definitions (i.e., the

presence or absence of physical disease and disability); consideration of adolescents’ health-compromising

behaviors; positive components of health (e.g., social competence, health-enhancing behaviors); and health

and well-being from the perspectives of adolescents themselves (e.g., perceived quality of life). A fully realized

view of adolescent health would also consider the impact of social (e.g., families, schools, communities,

policies) and physical (e.g., fluoridation, automobile and highway design and construction) influences on

health and would be sensitive to the developmental changes that occur during adolescence.

However desirable new constructs are, the possible consequences of expanding the definition of health

for adolescents should be considered.

1 l~s Coqeme was noted in the materials announcing the World H14th ~ganization meetings on the health of youth (334a).

SOURCE: OffIce of lkchnology Assessment 1991.
1-6 ● Adolescent Health--Volume I

these issues as well as those affecting younger

adolescents was probably too ambitious an undertaking. 8

In many cases, data on adolescents ages 10

through 18 are not available. Where necessary, OTA

relied on data aggregated for age groups that

included some or all of the ages that are the focus of

this Report,

Organization of the Report

OTA’s Adolescent Health Report has three volumes:

● Volume I, “Summary and Policy Options, ’

. Volume II, ‘‘Background and the Effectiveness

of Selected Prevention and Treatment Services, ’ and

● Volume III, “Cross-Cutting Issues in the Delivery of Health and Related Services. ”

This volume, Volume I, summarizes the findings of

OTA’s Report and presents the policy options

arising from OTA’s analysis. First it presents the

major findings and policy options. Then it summarizes specific findings and additional policy options

from chapters in Volumes II and III of the Report.

Finally, it presents a discussion of selected barriers

to and opportunities for change. Extensive bibliographic citations and data sources for health problems and utilization of specific services are cited in

the individual chapters in Volumes II and III. A table

of contents listing the chapters and appendixes in

each volume is included in appendix A, ‘‘Method of

the Study. ”

Major Findings

Are American Adolescents Healthy?

OTA’s analysis is based on a broad range of

measures of adolescent health and a correspondingly

wide variety of sources of data. OTA’s analysis,

described below, as well as analyses by other groups

(8,29,148,150,153), suggests that the conventional

wisdom that American adolescents as a group are

so healthy that they do not require health and

related services is not justified. On the other hand,

Figure l-Growth Spurts During Adolescence

Height

! 1

1’

Bi-iliac /*\ ,’ \ / ‘. . ,f ‘. // ‘\ / \

~= /~

Hand length

-.

“, Head Circ. ,--- ‘\, : ‘I \ /

\ !’ \

\ /

\

/

\ ’

\ \ ;

\ /’ \/

... - /t ‘ .

--/

Weight

1 , 1 , , , , 1 J

8 9 10 11 12 13 14 15 16 17 18

Age, years

SOURCE: Figure 5on p. 13 in J.M. Tanner, Growth at Adolescence, 2d ad.

(Oxford, England: Blackwell Publications, 1962) based on L.

Reynolds and G. Schoen, “Growth Patterns of Identieal Tripiets

From 8 to 18 Years,” American Joumalof PhysicdAnthropology

5:165-200, 1947. Copyright 0 1947 by John Wiley & Sons.

Reprinted by permission of Wiley-Liss, a Division of John Wiley

& Sons.

the seemingly contradictory conventional wisdom that adolescence is and should be a problem

period —that to be normal is abnormal—is also

unjustified.

Adolescence—roughly the second decade of life--

is a period of profound biological, emotional,

intellectual, and social transformation, unmatched

perhaps by any other period in life. The physical

changes are dramatic. One sees not only changes in

height, weight, and head size (see figure 1), but also

~One shou]~ no[ inte~re[ OTA’S deasion to limit its foeus to 1 @ through 18-year-olds as an iIIdiCatiOn that yOUng peOple of co~ege age have no

health-related problems deserving of attention, Young people of college age have a number of concerns. For example, the health insurance status of

individuals of college age is often ambiguous (159); employment opportunities for non college youth are minimal (330); and new health problems may

begin to emerge (263).
.

Summary and Policy Options . /-7

Photo credit: Education Week

Adolescence is a period of profound biological, emotional,

intellectual, and social transformation.

changes in facial structure and facial expression and

the ‘ ‘spectacular development of the reproductive

system’ (202). There may be emotional upheavals.

Intellectual capacity deepens, and adolescents gradually become capable of higher order thinking and

reasoning. The expectations of the larger society and

of family members, teachers, friends, and others in

Figure 2—Overall Death Rates Among the U.S.

Population by Five-Year Age Groups, 1987a

Years

Total

Under 1

1-4

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

F

872,4 —

1,018.5

51.6

{ 24.4

I

26.9

84.6

113,2

120.6

145.2

186.3

&

247.7

385.5

625.5

967.4

@k=51361

8,161.8

0 2 4 6 8 10

Deaths/100,000 population

aAlthough this OTA report focuses on adolescents ages 10 to 18, the data

here are for 5-year age groups and therefore indude 19-year-olds.

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, Centers for Disease Control, National Center for Health

Statistics, unpublished mortality data, Hyattsville, MD, 1990.

the adolescent’s immediate environment change,

sometimes leading to confusion about issues of

independence, conformity, and responsibility. These

extraordinary events, though perhaps related, are

typically discontinuous—they do not occur smoothly,

predictably, or simultaneously. Furthermore, some

adolescents are early and others are late ‘bloomers’

(62).

If, as an overview of adolescent development

suggests, adolescence is often a somewhat turbulent

period, it may be surprising that adolescents appear

by some traditional measures-i. e., mortality ratesto be among the healthiest of Americans. Adolescents as a group have among the lowest overall death

rates of all Americans in the United States (see figure

2). 9 The leading causes of death among adolescents

are somewhat different from those of other age

groups, however, with adolescents being more likely

than younger and older Americans to die of injuries

9Adolexents ~lso have the lowest ~u~~r of ~u~atient visi~ to office. based physici~ per person per ym and are among the least likely tO &

hospitalized, but the implications that can be drawn from those statistics about adolescents’ needs for services are not entirely clear. Wu_iOus factors may

affect adolescents’ utilization of maimtrearn health services, and many of them are discussed below and in several chapters in Vol. III, specifically, ch.

15, $ ‘Major Issues Pcrtainmg to the Delivery of Primary and Comprehensive Health Services to Adolescents’ ch. 16, “Financial Access to Health

Services’ ch. 17, ‘ ‘Consent and Cordldentiahty in Adolescent Health Care Jkcisionmaking’ and ch. 18, ‘‘Issues in the Delivery of Semices to Selected

Groups of Adolescents, ’
I-8 . Adolescent Health--Volume I

Figure 3-Death Rates Among U.S. Adolescents

Ages 10 to 19,a by External Causes of Death, 1987

Deaths/100,000 100

8 0

6 0

4 0

20

n

— -- ————

84.6

q

-., = Ages 10 to 1 4

-<,. ,<-. ~,’- 67.3 = Ages 15 to 1 9

‘All cause:

Ages 10 to 19

10.3

1.5

All injuries’ Accidents Suicide Homicide

Cause of death

aAlthough this OTA report focuses on adolescents ages 10 to 18, the data

here are for 5-year age groups and therefore indude 19-year-olds.

bIIAll causes” includes injuries and diseases. The rates at whikh causes Of

death other than injuries occurs in the adolescent population are relatively

small-e. g., malignant neoplasms, the next highest cause of death after

injuries, occurs in 10- to 19-year-olds at a rate of 3.7 per 100,000

adolescents ages 10 to 19.

c

"All injuries!’ includes accidents, suicide, homicide, and other injuries.

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health Service,

Centers for Disease Control, National Center for Health Statistics, unpublished 1987 mortality rates, Hyattsville, MD, 1990.

(including accidental injuries,10 suicide, and homicide

ll) (see figures 3 and 4).

Up-to-date information on U.S. adolescents’

health is often unavailable or deficient. This problem

is discussed further in appendix C, ‘‘Issues Related

to the Lack of Information About Adolescent Health

and Health and Related Services. ” Nevertheless,

available data indicate that American adolescents

have a number of health problems that should

be-and many have been--of intense national

concern.

Family problems--Some adolescents come

from homes with high levels of stress or

conflict and have experienced physical, sexual,

or emotional abuse. In 1985, an estimated

120,000 adolescents were in foster care (330).

The rate of maltreatment (defined as physical,

emotional, or educational neglect, or physical,

emotional, or sexual abuse) is believed to be

higher among adolescents than among younger

children (8,259). Data from the U.S. Department of Health and Human Services (DHHS)

National Center on Child Abuse and Neglect’s

national incidence study suggest that between

620,000 and 700,000 adolescents ages 10 to 17

were maltreated in 1986 (259). The consequences of abuse include depression and other

psychological difficulties during adolescence

and adulthood and may include delinquency

(329) and hopelessness (259).

School problems-On average, 12.6 percent

of 16- to 24-year-olds living in households

report not having completed a high school

education (the so-called status dropout rate

(250)); the proportion is higher among Hispanl~o tie~s Repfl mom acc~sible t. tie lay r~der and for other reasons, OTA has cho~n to use tie te~ accidenti inJW in ~s RePofi. ‘e

term preferred by those in the injury prevention community, however, is unintentional injury (e.g., 184). Those who prefer the term unintentional injury

believe that the term accidental injury implies that injuries cannot be prevented, whereas the tenrn unintentional injury implies that while an individual

may not have consciously intended to hurt him or herself, some action taken or not taken may have prevented the injury. Perhaps to overstate this

perspective somewhat, all injuries are thus avoidable. The position that true ‘accidents’ do not occur (that is, by chance, entirely without cause) correctly

brings attention to injuries as a public health problem to which additional preventive interventions can and should be applied, but it seems to be

unprovable. Use of the term “unintentional’ also may have the unfortunate effect of placing the onus of causation (and responsibility for precautions)

exclusii’cly on the person who is injured, although in fact unintentional injuries may be caused, atthough unintentionally, by persons, organimtions, or

systems other than the victim.

I l~e ~mce be~een inju~.related deaths (often called ‘ ‘external’ causes) and deaths resulting from ‘ ‘mtural’ causes changes over tie life sPan.

(It has also changed over time (288).) For Americans ages 1 to 4, “natural” causes of deatb (28.5 per 100,000 population in 1985) are somewhat greater

than “external” causes of death (23.0 per 100,000 population in 1985) (288); by ages 5 through 9, “external’ causes (13.0 per 100,000 population in

1985) begin to account for slightly more deaths than “natural” causes (1 1.8 per 1OO,O(XI population in 1985) (288). Ln the age group 10 to 14, the ratio

of ‘external’ to ‘‘natural’ causes of death is greater (16.5 deaths per 100,000 population for “external’ causes v. 11.4 deaths per 100,000 population

for ‘natural’ causes, in 1985), and by ages 15 to 19, ‘‘external’ cases of death (63.5 deaths per 100,000 population) clearly predominate over ‘natural”

causes (17.7 deaths per 100,000 population (288). (In the analysis relied on for the foregoing comparisons, “external’ causes of death include those

from motor vehicle injuries, fme and flames, drownings, homicide and suicide; ‘‘natural’ causes of death include those from malignant neoplasms

(cancer), congenital anomalies, and heart disease (288).) In contrast, the leading causes of death for persons ages 25 to 64 are cancer (133 deaths per

100,ooo ~pulation in 1987) and coronary heart disease (135 deaths per 100,000 population in 1987), followed by accidental injuries (approximately

30 deaths per 100,000 population in 1987), stroke (approximately 22 deaths per 1OO,(XXI population in 1987), and swcide (approximately 20 deaths per

100,000 population in 1987) (260); for persons 65 and over, heart disease, cancer, stroke, chronic obstructive lung disease, and pneumonia and influenza

predominate (289).
Summary and Policy Options . i-9

Figure 4-Trends in Death Rates for the Five Leading Causes of Death Among U.S. Adolescents

Ages 10 to 14 and Ages 15 to 19, 1970-87

Adolescents ages 10 to 14

Deaths/100,000 population

70 ~-—

II + Accidents and adverse

t

40 +

effects

Malignant neoplasms

Ii + Major cardiovascular

It problems

30 t I + Suicide

++ Homicide and legal

intervention

2 0 *

) ,“

v

10 I

o

1970 1975 1980 1985 1987

Adolescents ages 15 to 19

Deaths/100,000 population

70

T

60

50

40

30

20

10

$

1

[

o

--w Accidents and adverse

effects

+ Malignant neoplasms

-B- Major cardiovascular

problems

_Zk_ Suicide

+ Homicide and legal

intervention

I I I

7

1970 1975 1980 1985 1987

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Services, Public Health Service, Centers for Disease

Control, National Center for Health Statistics, Viia/ Statistics of fhe United stabs 1970, Vol. //-Mortality (Washington, DC: U.S. Government

Printing Office, 1974); U.S. Department of Health and Human Services, Public Health Serviee, Centers for Disease Centrol, National Center for

Health Statistics, Vita/ Statistics of tie United Stabs 1975, Vbl. //-Mo-rta/ity (Washington, DC: U.S. Government Printing Office, 1979); U.S.

Department of Health and Human services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Vi’td StWMC.S

of the Urrited States 1980, W. //-#orta/ity, Pub. No. (PHS) 85-1101 (Washington, DC: U.S. Government Printing Office, 1985); U.S. Department

of Health and Human Serviees, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Wta/ St#stks of the United

States 1995, Vo/. //-Mortality, Pub. No. (PHS) 88-1102 (Washington, DC: U.S. Government Printing Office, 1987); and U.S Department of Health

and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, unpublished 1987 mortality data,

Hyattsville, MD, 1990.

ics, blacks, and persons living in central cities

(see figure 5).12 According to one observer,

high dropout rates are one indication of the

failure of schools to meet their students’

educational or social growth needs (74). Adolescents drop out of school for a variety of

reasons—boredom or academic failure, health

problems (e.g., mental health problems, substance abuse problems, pregnancy), and family

financial or other problems. Whatever their

reasons for their dropping out, however, adolescents who do not complete high school will

likely be unable to realize their potential in the

U.S. labor force and are likely to be at increased

risk for a wide variety of health, economic, and

social problems (e.g., underemployment, unl~t is ~w~tt. note ~~-.m~tiom of ~ucm~sfil ~hml ~ompletion (~d Convemely, ~h~l p~blems) me ~@y dqent on the definition

used, the data source, and the level of detail to which the data are pursued. Shown here is the average proportion of those individuals ages 16 to 24 living

in households (and thus responding to the household-based Current Population Suxvey) who have not completed high school (including the completion

of the general educational development (GED) test). However, if the same data source is us@ but high school graduates as a proportion of 17-year-olds

in the population is used as the indicator of successful school completion then an average of only 74 percent of 17-year+lds have successfully completed

high school (249). Another indication is the graduation rate defti as the percentage of 9th graders who have graduated 4 years latex (71.2 percent in

1989 (250a)). Graduation rates differ considerably by State and, within States, by school district and race, et.tmicity, and socioeconomic status of the

school population (e.g., 29; and see ch. 4 in Vol. II, “Schools and Discretionary Time”). However, all sources are consistent in that school problems

tend to be more prevalent among Hispanic, black and central city adolescents.
1-10 ● Adolescent Health-Volume/

Figure 5-High School Dropout Rates in the

United States, 1989° b

Percentage of dropouts among

individuals ages 16 to 24

3 6

24

12

0

33%

12.6%

16.4%

B.----l 12.4%

13.8%

Total U.S. Central White

1

Black Hispanic c

cities

aDropout rates shown in this figure are status dropout rates (the Proportion

of individuals of a specified age who are not enrolled in school and have

not finished high school at any given point in time) among individuals ages

16 to 24 as of October 1989.

bThe data on which this figure is based are Current Population Survey data

from the U.S. Department of Commerce, Bureau of the Census.

cHispanics may be of any race.

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Education, Office of Education Research and improvement, National C+nterfor Education Statistics, DfOpoUf R8ki+SifI

the United Stabs, FJCES 90-659 (Washington, DC: September

1990).

●

●

employment, welfare dependency, and homelessness) (79). 13

Lack of recreational opportunities--Opportunities for adolescents to engage in recreational or other activities that are attractive,

satisfying, conducive to health, and acceptable

to the adult community during their discretionary (nonschool) time are often perceived by

adolescents and other informed observers to be

inadequate.

Chronic physical illnesses--Many adolescents experience acute physical problems, such

as acute respiratory illnesses, which are the

leading cause of school-loss days, but an

estimated 5 to 10 percent of adolescents experience a serious chronic physical condition, for

example, hay fever or allergic rhinitis without

asthma (9. 1 percent of adolescents), chronic

sinusitis (9.0 percent), asthma (5.8 percent), a

“deformin g or orthopedic impairment” (5.4

percent), chronic bronchitis (3.9 percent), migraine headaches (2.9 percent), heart disease

(2.2 percent), hearing impairments (2.1 percent), and visual impairments (1.9 percent) 14

(291).15 Another indication of the prevalence of

serious chronic conditions among adolescents,

but which includes emotional disorders, is the

finding that approximately 5 percent of 10- to

18-year-olds in 1988 had a limitation in a major

activity (i.e., were not able to attend schooll6)

130TA did not ~omider how ~olexenfs’ ~v~lvement ~ work ~wts ~fi h~~ &WN@ to tie W,T.-tFou&tio~ ahut ow-fhhd of dl

high school students hold part-time jobs in any given week, and three-quarters of all high school seniors work an average of 16 to 20 hours a week (79).

Some evidence suggests that the income (and, perhaps, peer and adult associations) associated with work are a risk factor for illicit drug use

(64,80, 135,182,197). On the other han~ the opportunity for adolescents to participate in work or other constructive activity may have positive effects

on adolescents’ health such as increased self-esteem resulting from the gaining of competency.

14Tflf.semost prev~~t co~fio~ me ~t~~~y the ca~s of the major limitations inactivity noted belOW, the ~c~tio~ of ~tivi~ ~~tions

and prevalence of conditions were done separately (291). Further, the fact that the National Health Intemiew Survey sample of adolescents is so small

(and the fact that the sample is drawn solely from the noninstitutionalized population) means that the extent of lower prevalence of very serious chronic

conditions such as muscular dystrophy, Down’s syndrome, cystic fibrosis, hemophilia seizure disorders, aua and arthritis is not known. Another

important point is that drawing the information from an informant rather fhanfrom the adolescents themselves may limit the reporting of some conditions.

FW.her details on the prevalence of chronic physical conditions, and discussions of variations in definitions of chronic and serious, can be found inch,

6, “Chronic Physictd Illnesses: Prevention and Services,” in Vol. II.

ls~mer and s~petileld’s comprehensive review can also be used to support the estimate of 5 to 10 penxnt pNvd- h Cbnic Problm, ~t

also with the caveat that the conditions included in the Gorfmaker and Sappenfield review varied in severity (78). Based on a variety of some+

Gortmaker and Sappetileld cakndated that 13.3 percent of individuals ages O to 20 had a chronic conditiom with the most prevalent conditions being

asthma (3.8 pereenc 1 percent of which was moderate to severe), visual impairments (3 percent), mental retardation (2.5 pereent), and hearing

impairments (1.6 percent) (78). If, as Gortmaker and Sappenfield estima@ 90 pereent of the individuals with a chronic disorder survived until age 20,

and assuming that all chronic disorders listed by Go rtmaker and Sappenfield persisted into adoleseenee, 12perceru of 19-year-olds would have a chronic

disorder. Assuming that asthma is not as severe a problem for adolescents as for younger children (and to make a rough adjustmen~ excluding the 1.8

percent of asthma that is not moderate to severe), and excluding mental retardation (2.5 percent of O- to 20year4ds), autism (0.04 percent), and Down’s

syndrome (O. 1 percent) from the total (in order to be comparable to OTA’s estimate based on National Health Interview Survey data and beesuse eh.ildrcn

and adolescents with such disorders are served by a distinct service system), would reduce the proption of adolescents with a chronic physical condition

to appro ximately 8percenr. Perhaps not all of these conditions would be considered “serious’ under the conventional deftition. Conditions are typically

deemed serious if they result in a limitation in a major activity.

16~ ~V5 such ~ tie Natio~ H~~~@rview survey, persons are classified in terms Of the major Wtivity u~Y ~~~ W_iti ~~ %e grouP;

attending school is considered the major activity for the age group 5 to 17. Persons are not classified as having a limitation in a major activity unless

one or more chronic coti”rion is reported as the cause of the activity limitation (286).
Summary and Policy Options . /-11 —

due to a chronic condition (291). However,

fewer than 1 percent were completely unable to

carry on a major activity (291).

Two problems that may not be considered

serious in and of themselves, but are of concern

to many adolescents, are acne and menstrual

distress (dysmenorrhea). About 9 percent of

adolescents experience serious, chronic acne

(291), and perhaps 50 percent of female adolescents have missed school or work because of

menstrual distress (100,33 1). These problems

are noteworthy because they suggest a wide

gulf between what adolescents and what adults

feel are important issues to be addressed by the

health service delivery system.

Nutrition and fitness problems—Adolescentspecific data on nutrition and fitness, aside

from average nutrient intake information, are

limited, but if one accepts the conventional

wisdom concerning nutrition and fitness needs,

it appears that many adolescents experience

some nutritional or fitness problem (usually

mineral deficiencies, imbalanced diets, or overweight or obesity). According to data from a

variety of sources, female adolescents are

especially prone to nutritional deficiencies.

Those female adolescents who are pregnant

(e.g., 275) or athletes are particularly prone to

nutritional problems. National information on

the nutritional and fitness problems of poor

adolescents and of many racial and ethnic

minority adolescents is not available.

Dental and oral health problems--Adolescence is a pivotal period with respect to oral and

dental health, in part because of the physical

changes of adolescence and in part because of

the transition from childhood to increasing

personal responsibility for oral hygiene. Some

adolescents do not have access to fluoridated

water supplies or are unable to afford regular

dental care, and for these adolescents and

others (e.g., those with rampant caries), dental

caries remains a significant problem. In addition, many U.S. adolescents need moderate

treatment for gum disease, and some groups of

adolescents (e. g., American Indians) have more

serious periodontal problems.

—

●

●

Acquired immunodeficiency syndrome (AIDS)

and other sexually transmitted diseases (STDs)

—Many U.S. adolescents are sexually active

and at risk for problems associated with involvement in unprotected sexual intercourse. 18 I n

1988, more than half of 15- to 19-year-olds

reported having had sexual intercourse in the

last 3 months (68), but only 22 percent of

sexually active female adolescents ages 15 to

19 reported current use of condoms (141).

Condoms are the only known protection against

AIDS, human immunodeficiency virus (HIV)

infection and STDs for the sexually active.

Recent data from the Centers for Disease

Control suggests that, in 1989, 30 percent of

newly reported gonorrhea cases, and 10 percent

of newly reported syphilis cases in the United

States occurred among 10- to 19-year-olds (12).

The percentages of U.S. adolescents estimated

to have specific STDs vary, depending on the

disease and population on which the data are

based (see figure 6).

Pregnancy and parenting—About 1 million

U.S. adolescents become pregnant each year;

about half of these adolescents obtain abortions, and about half of them give birth (see

figure 7). U.S. adolescents are having children

out of wedlock at dramatically higher rates than

in the past. About 65 percent of births to U.S.

adolescents in 1988 were out-of-wedlock births

(294). Adolescent mothers and their infants are

Photo credit: March of Dimes Birth Defects Foundation

About half a million U.S. adolescents give birth every year.

17BY the ~n{l ~~ ~do]escence, for exmlp]e, two out of five American Indian dental patients have destructive periodontal disease Witi ~ne loss (295).

]~[jnpr{)fe(.fe(~.ferua/~nrdrcour,fcrefers[0sexual Intercourse wl~ou(me use of condoms to prevent tie mmmission of AIDS ad STDS and without

the use of contraception 10 prevent pregnancy.
I-12 . Adolescent Health-Volume I

Figure 6--U.S. Adolescents With HIV Infection or Sexually Transmitted Diseases (STDs):

Percentage of population National and Local Estimatesa b

6 8 ~– ‘- – —

64 4 National dataa Local datab

6 0

5 6

52 -

4 8

44

40 –

36 -

32 -

2 8

24 –

20 –

16 -

12 –

8– .0014 .0042 7

37’

I

28° 1

18.5 n

I I

:=280%37’4 1=1 083: ‘l-- =0° ’10’ -il 1 “

Syphili s

c

’

d Chlamydi a

h,i Gonorrhea e,h Canal id iasis h,r

HIV

Gonorrhea C’

c

infect ion h.i SyphiIis “h Herpes h,q CondyIoma

accuniinatum h ‘

t

= Ages 10-14 Ages 15-19 ~ Lowest rate m Highest rat e

NOTE: National data not drawn to same scale as local data. pUblished publi shed

aThe Centers for Disease Control (CDC) in the U.S. Department of Health and Human Services collects national data on syphilis and gonorrhea, but national

data on other STDs are not available. CDC recommends that States report particular STDs, but has no authority to require such reporting (48,274). Thus,

there is no uniformity in State reportng requirements for STDs. Even in the States that do report STDs, there are incomplete reporting requirements for STDs,

differences in reporting by public and private health sources, and limitations in the spedficity of diagnostic tests (1 7,1 23).

b

local data are obtained from different studies using varying sample sizes. The studies and selected pertinent details of each study are listed in footnotes

below.

cThis is a population incidence rate, which is the measure of the number of new cases of a particular disease or condition occurring in a population during a

given period of time.

dSyphilis ss caused by the bacterium Treponerna palladium.

eGonorrhea is caused by the bacterium Neisseria gonorrhoeae.

fThis figure is from a study conducted on 510 runaway and homeless youth, age 18 or under, who were residing in Covenant House in New York City in 1987-68

(200).

gThis figure is from a study conducted on 12,344 adolescent mothers (age 18 or under) of newborns, who were age 20 or less, in upstate New York in 1987-88

(162). The same study tested 12,871 adolescent mothers (age 18 or under) of newborns in New York City and found a clinical prevalence percentage of 0.72.

hThis is a clinical prevalence rate, which is a measure of the number of individuals in a given clinical population who have a specific disease or other condition

at a designated time (or during a particular period).

iHIV (human immunodeficiency virus) is the virus assodated with acquired immunodeficiency syndrome (AIDS).

This figure is from astudyoonductedon115 low-income, pregnant, predominantly black females, ages 13to 19, who were receiving prenatal care in the Johns

Hopkins Adolescent Pregnancy Program (69).

kThese data are from a study conducted on 948 sexually active asyrnptomatic adolescent males, ages 13 to 19, who were attending teen or detention clinics

in San Francisco, CA (188).

l

chlamydia infection (formal name, “nongonoccal urethritis”) is caused by the bacterium Chlamydia trachomatis.

mThis figure is from a study conducted on 2,521 adolescent males and females, ages 9 to 18, who were in the New York City Juvenile Detention Center (4).

nThisfigure is from a study conducted on 567 adolescent males and females who were visiting the Adolescent and Young Adult Clinic of the Children’s National

Medical Center in Washington, DC (45).

oThis figure is from a study conducted on 100 low- and middle-income, sexually active, adolescent females from urban areas, who were attending the

Adolescent Clinic of the Children’s Hospital Medical Center in Cincinnati, OH (185).

pThis figure is from a study conducted on 376 inner-city, iow-income females, ages 12 to 18, who were seeking contraceptive counseling at the Teen Accent

Clinic in Birmingham,AL(163).

qHerpes is caused by the herpes simplex virus (HSV).

rCandidiasis is caused by the bacterium Canddiasis albicans.

sThis figure is from a study conducted on 89 low-income, sexuaily active, primarily black females, ages 13 to 19, who were attending an adolescent clinic of

the University of Maryland Hospital in Baltimore, MD (128).

tCondyloma acuminatum is caused by human papillomavirus.

SOURCE: Of fioe of Technology Assessment, 1991, based on the sources noted above.
. —

Summary and Policy Options .1-13

Figure 7-Overview of U.S. Adolescent Pregnancy and Parentinga

Percent

100

9 0

8 0

7 0

6 0

6 0

4 0

3 0

2 0

10

0

U.S. adolescent

males, ages 16 to 18

64.0%

3 3%

15yr.

old S

U.S. adolescent

females, ages 15 to 19

53.2%

1

11%

4 .6% 5%

3.3%

1.5%

[ 1 1

0.13%

Ever had Ever had Pregnant Had an Had a Gave Had an Gave a

sexual sexual in the abortion miscar- birth Out-of - baby up

i n te rc ou rs e i n te r- past in the r i ag e in the wedlock f o r

course year past i n t h e past birth adopt ion

year pas t year in t h e in the

year past past

year year

Pregnancy-related event

a

Percent of sexual intercourse, pregnancies, and out-of-wedlock births were tabulated from 1988 data. Percentages of abortions, mlscarriages, and births

were tabulated from 1984 data. Percentages of adoptions were tabulated from 1982 data.

SOURCE: Office of Technology Assessment, 1991, based on data from the following sources: Adolescent males ever had sexual Intercourse: F.L.

Sonnestein, J.H. Pbck, and L.C. Ku, “Patterns of Sexual Activity Among Adolescent Males,” paper presented at the annual meeting of the

Population Association of America, Toronto, Canada, May 1990. Adolescent females ever had sexual Intercourse: J.D. Forrest and S. Singh,

“The Sexual and Reproductive Behavior of American Women, 1982-1988,” Farni/y P/arming Perspecdves 22(5) 220S214, 1990. Pregnant In the

past year: U.S. Congress, Congressional Budget Office, Sources of su~rt for Akdescent A.4ofhem (Washington, DC: September 1990). Had an

out-of-wedlock birth In the past year: U.S. Department of Health and Human Services, Public Health Servioe, Centers for Disease Control,

National Center for Health Statistics, Division of Vital Statistics, “Advance Report of Final Natality Statistics, 1988,” Modtr/y ViIStatisfics Reporf

39 (No. 4, suppl.), DHHS Pub. No. (PHS) 901120 (Hyattsville, MD: Aug. 15, 1990). All others: National Academy of Sciences, National Research

Council, Commission of Behavioral and Social Sciences and Education Committee on Child Development Research and Public Policy, Panel on

Adolescent Pregnancy and Childbearing, Risking the Future: Mo/escent Sexw/ity, Pregnancy and Chikbearing, Pd. /, C.D. Hayes (ad.)

(Washington, DC: National Academy Press, 1987).
1-14 ● Adolescent Health—Volume I

Photo credit: Education Week

Adolescents at one forum expressed their belief that

alcohol use is the most prevalent drug problem among U.S.

students. This belief is supported by national survey data.

●

typically in need of substantial services, ranging from child care to housing.

Mental health problems--According to a

survey of Minnesota students, an average of

one-quarter of adolescents report being ‘ ‘sad,

discouraged, and hopeless, ” experiencing extreme stresses and strains, dissatisfied with

their personal lives, or “tired, worn out, exhausted” (209). A national survey of 8th and

10h graders found that 34 percent of female

students and 15 percent of male students

reported feeling ‘ ‘sad and hopeless’ during the

month before the survey; 21 percent of female

students and 11 percent of male students

reported that it is ‘‘very hard for them to deal

with stressful situations at home and at school;

and 18 percent of female students and 9 percent

of male students reported that they often felt

that they had nothing to look forward to (10).

Diagnosable mental disorders,]9 ranging from

anxiety and depression to schizophrenia (but

●

primarily including conduct disorders), are

experienced by 18 to 22 percent of adolescents

(e.g., 43). In 1987, 15 percent of 10th graders

reported having made a suicide attempt (10).

Although many adolescents with mental health

problems do not get treatment, psychiatric

hospitalizations of adolescents have recently

been increasing (26,326).

Alcohol, tobacco, and illicit drug abuse 20

-

The consumption of alcohol places adolescents

at risk of immediate health problems (e.g.,

motor vehicle accidents) (315). In recent surveys of U.S. students, about one-third reported

that they had had five or more alcoholic drinks

on at least one occasion in the previous 2 weeks

(10,252). Adolescent participants at one forum

expressed their belief that alcohol use is the

most prevalent drug problem among U.S.

students (7), and that belief is supported by data

from a 1988 household survey on drug abuse

conducted by the National Institute on Drug

Abuse in DHHS (see figure 8) (263).21

Nicotine, most commonly in the form of

cigarettes, is used by a substantial number of

U.S. adolescents. The 1988 household survey

conducted by the National Institute on Drug

Abuse found that 11.8 percent of 12- to

17-yea.r-olds living at home had smoked cigarettes in the last month (see figure 8). It has

been well documented that cigarette smoking

over time places individuals at risk for lung

cancer and other life-threatening health problems later in life. The use of smokeless tobacco

also has significant health consequences (296),

but national surveys such as the household

survey conducted by the National Institute on

Drug Abuse do not request information about

smokeless tobacco use.22

The use of illicit drugs such as marijuana,

cocaine, inhalants, hallucinogens, heroin, or

lgDjagnosable mental disor(lers me disorders included in the American Psychiatric Association’s Dia~nostic and ,Ytatistical Manuul of Mental

Disorders, 3rd cd., revised, commonly known as DSM-IH-R (9).

m%t Comtitutes adolescent substance abuse---any use al all or “problem’ us~is a matter of controversy. The Office of Substance Abuse

Prevention in DHHS is of the view that any psychoactive substance use by adolescents should be prevented (272), The Ameriean Psychiatric Association

distinguishes between substance use, substance abuse, and substance dependence but these categories apply primarily to adults (9). These distinctions,

and laws prohibiting the sale of alcohol to adolescents in alt States, and tobacco to adolescents in many States (see ch. 12, ‘‘Alcohol, Tobacco, and Drug

Use: Prevention and Semices, ‘‘ in Vol. II), also lead to other concerns about terminology. In this Repoz OTA uses the terms ‘‘illicit’ or ‘illegal drugs

to characterize only those substances that it is illegal for U.S. individuals of all ages to use (e.g., cocaine, marijuana).

Z I me household smey on ~g abuse condll~ted by the National I~~titute on Dmg Abuse sampled about 3,~ 12- to 17-y~-olds living at home.

Homeless and institutionalized adolescents have not been systematically surveyed, ha] surveys and clinical experience have found that adolescents

who are homeless or institutionalized typically have higher rates of psychoactive substance use than do adolescents living at home.

ZZ~e one-time National Adolescent School Health Survey found that an average of 4.4 pereent of Ioth grade males us~ smokeless tobacco d~ly

(lo).
Summary and Policy Options . /-15

Figure 8-Overview of U.S. Adolescents’ Use of

Alcohol, Cigarettes, and Illicit Drugs, 19888

Alcohol

cigarette ’ -“”3’ I

Any illicit drugb~

24.7%

9.2%

Marijuana

,8% 1

Ever used

Used in past month

o 20 40 60 80 100

Percent

aData are from the 1988 Household Survey on Drug Abuse conducted by

the National Institute on Drug Abuse (NIDA) for 12-to 17-year olds. The

NIDA Household Survey on Drug Abuse measures the prevalence of drug

use among the American household population age 12 and over and

therefore does not include homeless or institutionalized adolescents. The

sample of adolescents in the 1988 NIDA survey was quite small (3,095 in

1988, including 747 blacks, 763 Hispanics, and 67 other nonwhites).

bAny illicit drug includes marijuana, inhalants, cocaine, hallucinogens,

heroin, and nonmedical uses of psychotherapeutics.

SOURCE: Office of Technologv Assessment. 1991. based on data from

●

U.S. Department o;~ealth and Hu’man Services, Pub4ic Health

Service, Alcmhol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, 1988 NW’ona/Househo/cf

Survey on Dmg Abuse (Rockville, MD: 1989).

nonprescription use of psychotherapeutics (sedatives, tranquilizers, stimulants, or analgesics)

appears to be far less common among U.S.

adolescents living at home than the use of

alcohol or tobacco (see figure 8). The problems

that illicit substances pose for the adolescents

who abuse or sell them, however, can be

substantial.

Delinquency-h 1988, there were 1.6 million

arrests of adolescents (301), and in 1987, about

700,000 adolescents were confined to public or

private juvenile justice facilities (306,308). In

recent years, the number of U.S. adolescents

confined to public and private juvenile facilities for delinquent acts 23 has been increasing

(305,306). Most of the increase has apparently

been due to an increase in the number of

——.—

Photo credit: Benjamin %ith, Wshington, DC

U.S. adolescents are more likely to be victims of violent

●

crimes than individuals from other age groups.

adolescents confined for minor offensesx (including status offenses 25) rather than serious

offenses (306,3 10).26 27 Adolescents confined

to public juvenile justice facilities are disproportionately black males (310). Many adolescents confined in juvenile justice facilities have

serious health problems upon entering the

facilities and have been found to lack adequate

health care while incarcerated.

It is important to note that adolescents

(especially black and male adolescents) in this

country are more likely to be victims of violent

crimes than individuals from other age groups

(see figure 9). Violence by adolescents and by

individuals from other age groups is a major

cause of injury and death among young people

(307).

Hopelessness-Some adolescents are homeless, either with their families or on their own.

In 1984, DHHS estimated (on the basis of 1976

data) that there are as many as 1 million

homeless and runaway adolescents each year

(256). Homeless and runaway adolescents are

z~De/inquent UCtS are aCLS that are committed by minors that would be considered crimes if committed by an adult Or are offe~~s o~Y ~~use ~eY

are committed by minors (e.g., truancy, running away from home)

MMinor ~, ~mre~ are Fedem] Bureau of Investlgahon pafi 11 offenses, which include aCtS tbt wouM ~ ~mes if commitl~ bY adul N (e.g., ‘ig abU$c ff

violations, weapons violations, assaults without w~?pons, disorderly conduct, and driving under the influence) and status offenses (299).

“SrUrU.T oflenses are offcn.ses that are considered offenses only because they arc committed by a person under the age of majority (e.g., running away

from home, truancy)

~,$crzous (jflense~ are Federal Bur~u of Investigation Part I offenses and include specified violent offenses (murder and nonnegligent manslaughter,

forctblc rape, robbery, and aggravated assault) and specified property offenses (burglary, larceny theft, motor vehicle theft, and amen).

~71n 1989, the number of adolescents held in publlc facilities for serious vlolcnt offenses ]ncreased for the first time since 1983 (3 I 1).
1-16 ● Adolescent Health--Volume I

Figure 9-Victimization Ratesa for Rape, Robbery, and

Assault by Age and Sex, -1988 -

Number of offenses experienced by

victims/l00,000 population 10,000

8,000

6,000

4,000

2,000

0

-r— — -

= Male = Female

m12-15 16-19 20-24 25-34 35-49 50-64 65+

Age of victims

aThe victimization rate is the number of offenses experienced by a given

population per some population base during a given time period. “

SOURCE: U.S. Department of Justice, Office of Justice Programs, Bureau

of Justice Statistics, Criminal Victimization in the United States,

1988 (Washington, DC: forthcoming).

at increased risk for a wide variety of mental

and physical health problems.

Further information on the prevalence of selected

health problems and an indication of which adolescents are most at risk are summarized in appendix B,

“Burden of Health Problems Among U.S. Adolescents, ‘‘ in Volume III of this Report.

Not all of the news is bad. One positive change is

the decline since 1970 in accidental injury death

rates among U.S. adolescents, for reasons that may

include successful prevention efforts such as increased use of safety belts, safer car construction,

and designated driver programs (158). Death rates

for some other serious physical health problems

(e.g., some types of cancer and major cardiovascular

disease, as shown in figure 4) have decreased,

largely as a consequence of medical advances. Also,

water fluoridation efforts have dramatically reduced

the prevalence of dental caries among the U.S.

adolescent population in the last decade (1 12).

Pregnancy rates for sexually active U.S. adolescents

ages 15 to 19 declined between 1970 and 1985

suggesting that at least some sexually active adolescents are making effective use of contraceptives.28

The percentage of U.S. adolescents living at home

and in school who report using illicit drugs has

recently decreased (252,263). Arrest rates for serious

violent and serious property offenses in the aggregate among individuals under age 18 have been

declining since the mid-1970s.

Nonetheless, the prevalence of health problems

among U.S. adolescents is disturbingly high, and

many health problems have been shown to be costly

in both human and economic terms. Available

information concerning the cost of various adolescent health problems is limited, but some of the

figures that have been cited are shown in box B.

Which Adolescents Experience

the Worst Problems?

The burden of health problems is not borne

equally by all U.S. adolescents, as shown in appendix B, “Burden of Health Problems Among U.S.

Adolescents, ‘‘ in Volume III. Nationally aggregated

data for all adolescents obscure important age, sex,

race, and income-related differences in the extent of

specific problems. Unfortunately, reliable populationbased information about the health status of adolescents from specific age, racial, ethnic, socioeconomic, regional, and residential groups is generally

not available. 29 Most available information on

adolescents focuses on older adolescents rather than

younger ones.

Age Differences in Selected Adolescent

Health Problems

As a general matter, older adolescents (roughly

ages 15 to 18) are more likely than younger

adolescents (ages 10 to 14) to experience health

problems. The implications when a young adolescent experiences a health problem such as drug use

or pregnancy, however, may be much more serious

than the implications when an older adolescent

experiences such a problem.

● Older adolescents (15- to 18-year-olds) are

more likely than younger adolescents (10- to

14-year-olds) to be reported to be limited in a

2S~ere app~ed t.& an incr=e &W~n 198s and 1987, however (s= “S~ifiC Fid@s and pObCI’ options, ’ ~low). ~bl~ in es~@

adolescent pregnancies are discussed inch. 10, “Pregnancy and Parenting: I%evention and Services, ” in Vol. II.

‘Age, sex, race, and income differences do not in themselves explain why certain adolescents are at high risk of certain problems.
Summary and Policy Options . 1-17

Photo credit: Jonathan Roberts

The implications when a young adolescent experiences

a health problem may be much more serious than the

implications when an older adolescent experiences

the same problem.

major activity30 due to my chronic 31 condition

(5.3 percent v. 4.4 percent), to have a chronic

orthopedic impairment (7. 1 percent v. 3.9

percent), to have chronic sinusitis (9.7 percent

v. 8.3 percent), to have acne (9.3 percent v. 3.5

percent), and to have a disease of the female

genital organs (1.3 percent v. prevalence so low

●

as to be undetectable among younger adolescents by the National Health Interview Survey

conducted by DHHS).

Younger adolescents (10- to 14-year-olds) are

more likely than older adolescents (15- to

18-year-olds) to be reported to have chronic

asthma (6.2 percent v. 5.4 percent), heart

murmurs (2 percent v. 1.3 percent), and speech

impairments (1. 1 percent v. prevalence so low

as to be undetectable in the National Health

Interview Survey) (291).32

Gender Differences in Selected Adolescent

Health Problems

Female adolescents are reported to experience

more days of restricted activity33 due to acute

conditions 34 than adolescent males (770.7 days

per 10015- to 18-year-old adolescent females;

664.7 days per 10010- to 14-year-old females;

629.2 days per 10010- to 14-year-old adolescent males; and 580.6 days per 100 15-to

18-year-old adolescent males). These differences are due in part to pregnancy-related

conditions, but there are also more reported

days of restricted activity among females due to

respiratory conditions (291).

Male adolescents are reported to experience

more days of restricted activity due to acute

injuries than females (133.5 days per 100

adolescent males v. 104.9 days per 100 adolescent females), and are more likely to be

reported to be limited in carrying on a major

activity due to a chronic condition (5.4 percent

of males v. 4.3 percent of females)35 (291).

~Inc]udcs physical corl~ition~ and mental (including emotiona! and behavioral) dlsOrdc~.

s I For Puwses of the National HeaJ(h Interview Survey, a condition is comidered ‘‘chronic“ “ if: 1 ) the respondent indicates it was first noticed more

than 3 months before the reference date of the interview and it exists at the time of the interview, or 2) it is a type of condition that ordinarily has a duration

of more than 3 months. Examples of conditions that are considered chronic regardless of their time of onset are diabetes, heart conditions, emphysem%

and arthritis (286).

~ZDifferences w~e not tested for statistical .$@lficanCe.

SI1n general, tie Nation~ Centm for Health Statistics defines a‘ ‘restricted activity day’ m one of tie follo~g fo~ tws of ~Ys in which a P~on’s

activity is restricted: 1 ) a bedduy, during which a person stayed in bed more than half a day because of illness or injury or was in a hospital as an inpatient;

2) a work-loss day, during which a currently employed person 18 years of age and over missed more than half a day from a job or business; 3) a school-loss

day, during which a student 5- to 17-years-old missed more than halfa day from the school in which he or she was currently enrolled; and 4) a cur-down

day, during which a person cuts down for more than half a day on the things he or she usually does. Work-loss, school-loss, and cut-down days refer

to the short-term effects of illness or injury. Bed days are a measure of both long-or short-term disability, however, because a chronically ill bedridden

person and a person with a cold could both report having spent more than half a day in bed due to an illness. It may be impwlant to note that natioml

surveys often rely on proxy respondents (e.g., parents, guardians) for individuals under age 17.

~For Puwoses of the National Health Interview Survey, a condition is considered ‘‘acute ‘‘ if: 1 ) it was first noticed no longer than 3 months before

the reference date of the interview, and 2) it is not one of the conditions considered chronic regardless of the time of onset. However, any acute condition

not associated with either at least one doctor visit or at least 1 day of restricted activity is considered to be of minor consequence and is excluded from

the final data produced by the survey (28.5).

SsRm$ons for not king able IO CW on a ~jor activity were not distinguished between physical conditions and mental (including cmotional and

behavioral) disorders.
1-18 ● Adolescent Health-Volume I

Box B—Economic Costs of Selected Adolescent Health Problems

Available information on the economic costs of adolescent health problems in the United States is presented

below. The information is incomplete but clearly demonstrates that the societal costs of adolescents’ health

problems are not insignificant. A deeper understanding of the full cost impact of adolescent health problems on the

health care system and on society as a whole is impeded by data limitations.

The cost estimates presented below are expressed solely in monetary terms. Some costs (e.g., years of healthy

life lost) are difficult to measure in terms of dollars. Alternative strategies that might be considered by policymakers

were discussed in a 1980 OTA report on cost-effectiveness analysis (219).

Estimated Costs of Selected Adolescent Health Problems

Health problem

●

●

●

●

●

Injuries

Severe and chronic mental,

emotional, and physical

disabilities

Families begun when parents were

adolescents

Mental health problems

Delinquency

Estimated cost and source

$39.4 billion in lifetime costs

associated with injuries sustained

1985 by 12.5 million adolescents

and young adults ages 15 to 241

$3.9 billion in health care costs

(1986 dollars)3

in

$16.65 billion in public costs for Aid

to Families With Dependent

Children (AFDC), Medicaid, and

food stamps (1985 costs)4

$3.5 billion in treatment costs for

adolescents ages 10 to 18 in 1986s

$2 billion or more a year on

confinement in public and private

juvenile facilities for perhaps 700,000

adolescents. 7

Important notes

Applies to individuals ages 15 to 24.

Data not available for adolescents

ages 10 to 18.

Applies to all individuals under age

21, not just to adolescents ages 10 to

18.

Note this is 1 year’s estimated costs

for all families begun when parents

were adolescents, not just costs for

adolescent-headed families in 1 year.

These are direct costs for treatment

provided only.6

These data also include juveniles

under age 10, but these constitute a

small fraction of the total.

Cost estimates for other problems experienced by adolescents, such as alcohol and substance abuse,8 AIDS or STDs,

are not readily available.

Caveats

. Primarily because of the limitations of available data, the costs noted above are not comparable. The costs are

inconsistent regarding the entity that incurs the cost (e.g., society, the entire health care system, a specialty health

care service system, publicly funded programs) and regarding the time during which the problems occurred (e.g.,

injuries sustained in 1985) or the costs were incurred (mental health treatment during 1986). The costs of injury,

for example, reflect lifetime costs, while the costs of mental health treatment include only estimates of resources

expended directly for the treatment of adolescents’ mental health problems. Also, various ages are represented in

the cost figures, from adolescents and young adults ages 15 to 24 (cost of injuries) to all individuals under age 21

(cost of disabilities).

The populations experiencing these problems may overlap (e.g., the costs of injuries includes adolescents with

disabilities) or be excluded (e.g., the institutionalized population is not included in the estimates on disabilities) from

the costs presented.

The costs of treatment and prevention noted above may not represent a level appropriate for adolescents’ needs

(26). Further, the appropriateness of the services represented in these costs is not evaluated here.

l~co~~ t. Rjce ~d ~cK~e, f~etime costs associated with injuries represent the monetary burden on society of injury-related

illness and premature death (179). The $39.4 billion estimate shown here includes both direct costs (e.g., expenditures for hospital care, physician

services, prescriptions, etc.) and indirect costs (e.g., Iong-texm morbidity costs, such as reduced productivity, and costs associated with premature

mortality, such as lost productivity) resulting from injuries sustained by individuals ages 15 to 24 in 1985 (129). Overall, adolescents and young
Summary and Policy Options . 1-19

adults ages 15 to 24 accounted for 22 percent of the injuries and 25 percent of the total cost of injuries experienced by the total U.S. population

in 1985. The estimate of lifetime costs was calculated by the authors using data from the National Health Interview Survey, the National Hospital

Discharge Survey, the National Medical Care Utilization and Expenditure Survey, the National Mortality Detail File, the National Council on

Compensation Insurance’s Detailed Claim Information data base, and the National Nursing Home Survey. The authors did not differentiate

between accidental injuries and intentional injuries (e.g., homicide or suicide).

% 1986, tie kidi.ag reported causes of disability among children and adolescents under age 21 (WCOUntiUg for ovm M of ~rt~

disabilities in this group) were mental and nervous system disorders (7.3 per 1,(XIO children and adolescents underage 21); respiratory disases

(6.0 per 1,000), musculoskeletal and connective tissue diseases (4.3 per I,O(M)), and eye and ear diseases and disorders (3.7 per 1,000) (159).

3New~h~k and MC-US aved at this estimate using data on disabilities wllected as part of the 1980 National Wdkd cm

Utilization and Expenditure SWey, a household-based survey of the noninstitutiomdized civilian population (159). Cost figures were adjusted

by the authors up to 1986 levels using the medical care wmponent of the Consumer Price Index. Because the survey’s definition of disability

included only those people with along-term limitation in usual activity, the “disabled” population represented in the survey may include a more

severely disabled subset of the population with chronic conditions. ‘I’he data are also limited by the small sample size (so that few children with

low preva.lenw chronic conditions are represented in the sample) and by the timing of the sample (in that the data were collected in 1980-81 when

more children were hospitalized, usually a more expensive treatment site).

‘$BUII’S es~te includes direct payments to sesvice providers, as well as the administrative costs of tke thrt% programs, but no intit

costs (such as morbidity and mortality due to maternat mortality among adolescents under age 15, low birthweight babies, loss of productivity

associated with school dropouts, etc.). Also, the estimate does not include other semiccs more likely to be used by families begun by an adolescent

birth than by other families, such as publicly supported social services, housing, special educational services, and child protective sewiws and

foster care. To calculate the costs to APDC and to Medicai~ Burt used estimates for 1985 expenditures (including adrmrua . . trative expenditures)

from the U.S. Budget, 1986. For estimates of food stamp expenditures, Burt used information from the Committee on Ways and Means, U.S.

House of Representatives (27).

5Bums md Tmbc USed data from the NatjoM Institute of Mental Health to calculate this estimate (see ch. 11, “NfentaI H4W mbl~:

Prevention and Services,” in Vol. II). Between 18 and 22 percent of U.S. adolescents have mental health problems requiring treatment; OIA

estimates that perhaps 6 percent actually receive treatment.

-e total costs of adolescent mental health problems for society (including indirect costs, such as losses in productivity or the burden

on public services) have not been quantifkd.

7Cost es~tes of juveties in fwilities are calculated by the Department of Justice, Oflke of Juvenile Justice Dd@uency -~tion

(306).

8~~oUgh it is es~t~ tit ~~ut 272,~ ~ole=nts me ~t~ Over tie co- of a y~ for ~co~l or su~tice abuse (267), there

is no information on the type of treatment (e.g., r~idential v. outpatient) those adolescents receive or its duration which makes estimates of the

total cost of these services for adolescents unreliable. (The costs of treatmextt are highly variable, with estimates ranging from $15,000 to $50,000

for medically intensive intermediate rehabilitation to $1,000 to $2,000 for low-intensity outpatient alcoholism programs to $150 to $300 for

slcohol education programs [335].)

SOURCES: Oftlce of ‘Ikchnology Assessment, 1991, compiled from &ta fmm the following soumes: Injuries: D. Rice and MacKenzie &

Associates, Cosr o~lnjury in the Unz”ted States: A Report to Congress 1989 (San Francisw, CA: Institute for Health and Aging,

University of California and the Injury Prevention Center, The Johns Hopkins University, 1989); W. M.az D.P. Rice, md EJ.

MacKenzie, “The Lifetime Costs of Injury,” Inquiry 27:332-343, Winter 1990. Disabilities: P. Newacheck and M. McManus,

“F.mancing Health Care for Disabled childre~” Pediatrics 81(3):385-394, March 1988. Pregnancy: M.R. Burt with F. Levy,

“Estimates of Public Costs for’lbenage Childbearing: A Review of Recent Studies and Estimates of 1985 Public Costs,’ in National

Reseamh Council, Commission on Behavioral and Social Sciences and l?ducatiom Committee on Child Development Research and

Public Policy, Panel on Adolescent Pregnancy and Childbearing, Volume II: Risking the Future: Adolescent Sexuality, Pregnancy,

and Childbeun”ng, S.L. Hofferth and C.D. Hayes (eds.) (WashingtorL DC: National Academy Press, 1987). Mental health: BJ.

Burns and C.A. lhube “Mental Health Services,’ contract paper prepared for the Office of ‘lbchnology Assessmen~ U.S. Congress,

WashingtoIL DC, 1990. Delinquency: U.S. Department of Justice, ~lce of Justice Programs, Offke of Juvenile Justice and

Delinquency Prevention Children in Custody, Z987, prepared by B. Allen-Hagen (Washingto@ DC, 1988).

Female adolescents are obviously the only adoles- . . Racial, Ethnic, and Socioeconomic Status

cents at risk of pregnancy. In addition, they are more Differences in Selected Adolescent Health

likely than males to be the victims of rape or sexual Problems

abuse. They are also more likely to report subjective

distress and to make suicide attempts than males. There appear to be a number of racial and ethnic

Male adolescents (especially older ones) are more differences in health and related outcomes.

likely than females to die as a result of accidental . White and black adolescents are about equal in

injuries, homicide, or suicide. Males are also more being reported to be limited in a major activity

likely to be victims of robbery or assault (307). due to a chronic condition (4.9 percent of white
1-20 ● Adolescent Health--Volume I

50

4 0

3 0

2 0

10

0

Figure 10-Percent Mortality Due to Seven Leading Causes of Death for Black and White U.S. Adolescents

Ages 10 to 14 and 15 to 19, 1987

Percent mortality

Whites

I Blacks

‘hites

Blacks

hites

d

Accidental Accidental Horn icicle

Whites

El Whites

B

Suicide Cardio - Congenital Malignant

i n j u r ies, injuries, vascuIar anomalies ne o pl asms

motor other disease

vehicles

= Ages 10-14 = Ages 15-19

SOURCE: Office of Tdnology Assessment, 1991, baaed on National Center for Education In Maternal and Child Health, Georgetown University, 7he Health

●

●

of America’s Yo~~Waahington, DC: September 1990).

adolescents and 5.1 percent of black adolescents), but white adolescents are more likely to

be reported to incur school-loss days 36 

as a ●

result of an acute condition (399.9 days per 100

white adolescents v. 302.8 days per 100 black

adolescents) (291).

Black, Hispanic, and American Indian/Alaska

●

Native adolescents drop out of high school at

higher rates than other adolescents (34,74).

Black male adolescents are in double jeopardy,

being more likely than white males to die as a

result of homicide (as shown in figure 10) and

also more likely than white males to commit

violent crimes and be arrested and incarcerated

for delinquent offenses (74).

White male adolescents are more likely than

black males or other adolescents to die from

motor vehicle and certain other accidents and

suicide (see figure 10).

Black and Hispanic females have high adolescent pregnancy and birth rates (61,74,320);

however, pregnancy rates of white adolescents

have been increasing faster than those of black

adolescents (146). In 1988,0.5 percent of black

10- to 14-year-olds and 10.6 percent of black

15- to 19-year-olds gave birth, compared with

0.06 and 4.4 percent of white adolescents in
Summary and Policy Options . /-21

●

●

●

those age groups37 (294). Comparable populationbased data on births to adolescents for other

racial and ethnic groups are not available

separately because of shortcomings in pre- 1990

Census data (294). Available data from 30

States and the District of Columbia suggest that

one-sixth of the Hispanic-origin births (476,082

babies) in 1988 were to females under age 20,

with wide variations in the incidence of adolescent childbearing among Hispanic groups (e.g.,

Mexicans, Puerto Ricans, Cubans, Central and

South Americans); in 1988, there were 8,455

American Indian and Alaska Native babies,

1,181 Hawaiian babies, and 5,394 Asian babies

born to females under age 20 (294).

Black non-Hispanic adolescents account for 36

percent of all adolescent (13-to 19-year-old, by

the Centers for Disease Control’s definition)

AIDS cases; Hispanic adolescents (all races)

account for almost 20 percent of adolescent

AIDS cases (280).

Mexican-Americans have high rates of obesity,

increasing their risk of eventually developing

Type 11 (adult-onset) diabetes (133).

American Indian adolescents are at high risk for

a number of health problems, in particular,

suicide, alcohol abuse, motor vehicle accidents,

mental health problems, substance use, pregnancy, and periodontal problems.

What accounts for these racial and ethnic differences is not entirely clear. While some of the

differences may be related to cultural factors, many

of them are more likely to be attributable to

differences in socioeconomic status. The proportion

of U.S. adolescents living in poor or near-poor

families varies considerably by race and ethnicity

(see figure 11). Differences in health status by

socioeconomic status are difficult to separate from

those of racial and ethnic differences, because there

is very little information collected that relates

adolescents’ socioeconomic status to their health.

One indicator of health differences by socioeconomic status is that in 1988, adolescents whose

family incomes were under $10,000 (7,8 percent)

were more than twice as likely as those whose family

incomes were $35,000 or above (3.5 percent) to have

a limitation in a major activity as a result of a chronic

condition (291). Other problems found more frequently among poor adolescents include poor physiFigure 11--Number of U.S. Adolescents Ages 10 to 18

and Number Living in Poor or Near-Poor Families,

by Race and Ethnicity, 1988a

Millions of adolescents — 32.5 f 31.00

3 0 -

27.5-

25-

22.5-

2 0 -

17.5-

15-

12.5-

10-

7.5-

5-

2.5-

0 -LJ8.37

—LJ3.70

= All Adolescents

m Adolescents

living in poor or

near poor families

4.84

3.21 .35

1. 10d

,/F.., ,

.80 .;

,

0

Total White b Black b Hispanic’ Asian American

Indian/

Alaska Nativeb

apoor and near-wr familie9 are those wtth incomes at or below 1 ~

percent of the Federal poverty level. Because 1988 population data are

not available disaggregate by Hispanic and non-Hispanic, yet poverty

statistics have been calculated for Hispanic and non-Hispanic, there is a

slight overcount for the white and black adolescent populations.

blnd~~s both Hispanic and non-Hispanic.

cpersons of Hispanic origin may be Of any mm.

%he Census Bureau is unable tocalcalate the number of Asian and Paafic

Islanders who are ages 10 through 18 for periods beyond 1980. OTA’s

rough estimate that there are approximately 1.100 million Man and

Pacific Islanders ages 10 to 18 is made by applying the estimated

proportion of AQan and Pacific Islanders who were ages 10 to 18 h 1980

(15.9 percent, derived by taking 9/17ths of the proportion of the Asian and

Pacific IsJander population who were under 18 in 1980 (30.2 percent)) to

the estimated total population of Asian and Pacific Islanders as of July 1,

1989. Better estimates of the 1 Gto 18-year+id Asian and Pacific Islander

population of the United States will be available from 1990 Census

statistics. Asian and Pacific islanders include Filipinos, Chinese, Vietnamese, Koreans, Japanese, Asian-Indians, and “others.”

SOURCE: Office of Technology Assessment, 1991, based on data from the

following sources: Adolescent population counts: U.S. Department of Commerce, Bureau of the Census, U.S. Population

Estimafes, by Age, Sex, Race, and Hispnb Origin: 1989

Current Population Reports, Series P-25, No. 1057, by F.W.

Hollmann (Washington, DC: U.S. Government Printing Office,

March 1890); S. Sue and N. Zane, “Health and Related Services

for Asian American Adolescents,” contract paper prepared for

the Office of Technology Assessment, U.S. Congress, Washington, DC, November 1989; F. Hollmann, Demographer,

Bureau of the Census, U.S. Department of Commerce, personal

commurkation dted in F. Butterfield, “Asians Spread Across a

I.md, and Help Change It,” The New York Times, Sunday, Feb.

24, 1991, p. 22. Number of adolescents Ilvlng In poor or

rtaar-poorfamllles: R. Kronick, Adjunct Professor, University of

California, San Diego, CA, calculations based on U.S. Department of Commerce, Bureau of the Census, March 1989 Current

Population Survey public use files, 1990.

cal health, depression, pregnancy, and criminal

victimization. For further discussion of socioeconomic differences in adolescent health, see chapter

18, “Issues in the Delivery of Services to Selected

Groups of Adolescents, ’ in Volume III.

JT~ese percent~es are derived from rates of birth presented by race of the baby, and maY not @ulY reflect tie race of tie metier (2 W).
1-22 Adolescent Health--Volume I

4 0

3 6

3 0

2 6

2 0

1 6

1 0

5

0

Figure 12—Use of Illicit Drugs by Different Adolescent Populations

Percentage

Used an illicit

drug immediately

prior to

commission of

illegal offense

Used an illicit 15.7

drug in the

last month

0 . 0

7.3

6.2

J_---- l

Ever used intravenous

drugs (lifetime prevalence)

34. 5

Ever used any

drugs intravenously

(Iifetime

prevalence)

0 . 4

Ever used

i n travenous drugs

(lifetime Prevalence

6.3

—

)

2 . 8

1

White Black Hispani c JuveniIe 12- to 17- Clinic DC CA S.F. Ml

12- to 17-yr-olds,

198 8

0ffenders, yr-olds i n sampl

198 7 household S, home

1988a 198 8

e,

less,

>

asample ~ize~ of ~ole=en~ were too small t. d~aggregate data on intravenous uss of drugs by racial and ethnic group.

bln~~es young adults over 18 as well as adole~ents.

U n represen tat i ve

student samples,

in various States

and San Francisco,

ages 13 to 18,

198 8

SOURCE: Office of Technology Assessment, 1991, based on data from the following sources: 12- to 17-year*ids living In households, 1988: U.S.

Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on

Drug Abuse, Natiorra/ Househoti Survey on Drug Abuse, 1988 (Rockville, MD: 1989). Incarcerated juvenile offenders, 1987: U.S. Department

of Justice, office of Justi@ Programs, Bureau of Justioe Statistics, Report to the Nation of Crime and Justice, 2d ad., NCJ-105508M (Washington,

DC: March 1988). Homeless adolescents and young adults, 1988: G. Yates, R. MacKenzie, J. Pennbridge, et al., “A Risk Profile Comparison

of Runaway and Non-Runaway Youth,” American Journal of F?iblic Heatth 78:820-821, 1988. Unrepresentative student samples, 1988: U.S.

Department of Health and Human Services, Public Health Service, Centers for Disease Control, “HIV-Relatad Beliefs, Knowledge, and Behaviors

Among High School Students,” Morbidity ancf A.forta/@ WeeMy F@ort37:71 7-721, Dec. 2, 1988.

Other Factors Associated With Differences in illicit and intravenous drug use as reported by

Adolescent Health Problems adolescents living in different locations and life

circumstances (e.g., adolescents living in houseIn addition to cultural factors and socioeconomic holds, incarcerated juvenile offenders, homeless

factors, a number of other factors may affect adolescents in a clinic, different States and cities).

adolescents’ health (rural v. urban, neighborhood,

lack of legal or financial access, and, of course, the One admittedly rough set of estimates by Dryfoos

occurrence of another health problem). As an suggests that 10 percent of adolescents ages 10 to 17

example of how problems vary by populations, see have multiple serious behaviorally based problems

figure 12, which illustrates differences in levels of (i.e., they have committed multiple serious offenses,
Summary and Policy Options ● 1-23

used multiple drugs, and have been sexually active)

(50,51). There is some evidence that these (and

other) multiple-problem adolescents are at somewhat higher risk for other problem behaviors such as

truancy and dangerous driving behaviors (49,59,99,165).

On the basis of their involvement in minor offenses,

marijuana and/or alcohol use, or sexual activity,

Dryfoos estimated that another 40 percent of 11- to

17-year-olds (and 62 percent of 15-to 21-year-olds)

were at moderate risk of multiple health problems

(50). Other evidence such as that accumulated by

OTA suggests that adolescents with multiple problems are at particular risk of lack of access to health

services (e.g., in juvenile justice facilities, for drug

abuse problems38). There is no one single source that

has evaluated the prevalence of the entire range of

possible health problems among adolescents (i.e.,

including emotional and physical, as well as behavioral, problems) or covariation among problems.39

What Causes Adolescent Health Problems?

In part because of uncertainty in the definition of

adolescent health and health problems, and in part

because of a lack of support for longitudinal and

other intensive and innovative research strategies, it

is difficult to pinpoint the factors leading to wellbeing or poor health. As the specific findings of this

Report indicate, even the causes of many longstanding problems remain largely elusive.40

For example, why do some adolescents engage in

potentially health-compromising ‘ ‘risky behaviors’

such as riding in cars without using safety belts or

with drunk drivers, having unprotected sexual intercourse, or using firearms in an unsafe way? What

causes some adolescents to be violent? Why have so

many adolescents attempted suicide? Why do so

many feel depressed and hopeless? Why do so many

drop out of school? Alternatively, why do some

‘ ‘resilient’ adolescents appear to do well in the face

of what seem to be seriously adverse family or other

circumstances? Likewise, the causes of some physical problems are unclear (e.g., leukemia, acne,

dsymenorrhea).

Photo credit: Education Week

Adolescents who do well seem to have strong and

developmentally appropriate social support, preferably

from their families, but if not from their families, from some

other adult or adults.

Having the answers to both the problem-oriented

and success-oriented questions is essential to the

design of effective preventive and treatment strategies. Although systematic, problem-specific evidence is scarce, some general themes emerged

throughout OTA’s analysis, some from analyses of

risk factors, and others from evaluations of change

interventions. Put positively, adolescents who do

well seem to have strong and developmentally

appropriate social support, preferably from their

families, but if not from their families, from some

other adult or adults. Similarly, schools that are

small, comfortable, safe, and intellectually engaging and emotionally intimate communities can

also make a difference in adolescent health and

well-being. Interactions with healthy peers, guided

by a caring and trained adult, have been shown

to prevent additional delinquent behavior.

~~sec Ch I z ‘‘Alcohol, Tobacco, and Drug Abuse: Prevention and Services, ’ in VO1. ~. . ,

39Co},arration is the tendency of he~th ~roblem~ t. ~ccur in tie ~~e indlvldua] at about tie we time. Most of tie evidence on COV~atiOn Of

adolescent problems IS based on cross-sectional studies, so it is still unclear for many problems whether one problem leads to another or the problems

occur together, due to a single cause or set of causes ( 165), Another limitation of the evidence on covariation is that most of the evidence is limited to

covanatlon in adolescent behaviors and does not consider emotioml or physical problems.

-e limitations of the knowledge base on particular adolescent health problems are discussed in a section below entitled “Specific Findings and

Policy Options ‘‘
I-24 . Adolescent Health-Volume I

Health care providers who are perceived as being

attentive to adolescent concerns ensure greater

compliance with treatment regimens. Evidence

about the potential positive impact of these kinds

of interactions suggests guidelines for changes in

adolescent environments, including the design of

services in a wide variety of areas. 41

What Should Be Done To Prevent and Treat

Adolescent Health Problems?

Interventions currently in place for adolescents

have been characterized as either prevention or

treatment. In general, prevention services are intended to prevent the occurrence of a problem (e.g.,

disease or condition). Conventional epidemiologic

definitions of prevention differentiate preventive

efforts as: 1) primary prevention (aimed at reducing

the incidence of a disease or other health problem),

2) secondary prevention (aimed at reducing the

prevalence of a problem by shortening duration

among those who already have the problem), and 3)

tertiary prevention (aimed at reducing complications) (1 14). With some exceptions, OTA’s analysis

of prevention services focuses most often on primary

and secondary prevention intervention efforts delivered to adolescents during their adolescence. Treatment services are intended to cure or ameliorate the

effects of a problem (e.g., disease or condition) once

the problem has occurred. 42

Although the distinction between prevention and

treatment services is used throughout this Report, it

is important to point out that in the case of

adolescents in particular, the line between prevention and treatment is not always clear. Adolescents

may have health concerns (e.g., problems in school,

need for family planning counseling or contraceptive services, subjective distress) that would not be

considered fill-blown clinical problems (e.g., a

learning disability, a conduct disorder, a pregnancy,

clinical depression) by the mainstream health services treatment system but that could benefit from

early clinical intervention. Perhaps more important,

interventions for these subclinical issues are not

typically financed by health insurers or public

clinics .43

Further, an appropriate concern regarding adolescent health services is the extent to which they

address the promotion of either specific aspects of or

overall adolescent health as opposed to being

focused on specific problems (39,137).

In no case-health promotion, problem prevention, treatment---does the evidence give comfort that

adolescent health problems are in general being

appropriately addressed by current health policies

and service delivery systems. There are numerous

examples of promising health promotion, problem

prevention, and treatment interventions, but they

have been implemented only sporadically. These

promising interventions can provide considerable

guidance for program implementation and the continuing design of more effective approaches.

dlney c~ot, of comse, be used to prevent such problems as Ieukemti asthma, and acne, but they can serve as a guide to interperso~lY WProPriate

treatment of adolescents with such problems.

42~evcntion effo~ cm ~so ~ ~ffer~tiated in v~ous o~er ways. One way is in terms of prevention strategy: ernpowerrnen~ h~th promotio~

health protection and preventive education (all forms of primary prevention) and screening and early clinicat services (often considered forms of

secondary prevention). Stilt other ways of differentiating prevention efforts are by intervention target (e.g., parents, teachers, individual adolescents,

peers, entire communities, or all of the above) and, especially for primary prevention by the age at which the intervention takes place (e.g., infancy, arly

or middle childhood, adolescence).

43~ ~xmple encOmtered by ~ OTA s~f member illus~ates tie problem. J~on w~ m 18-y~-old ~m a very disadvantaged f~fly @

neighborhood who said he wanted to graduate horn high school and join a branch of the military service so that he could travel and get a college education

or learn a trade. His mother was a long-time alcoholic who had had her fmt child at age 15, and had her first five children taken away by various child

protective services. Jason himself had been placed temporarily in foster homes a number of times, but was still living vvith his mother as he neared age

18. Jason+ his mother, and his teenaged sister lived in a one-bedroom apartment in a neighborhood riddled by drugs and violence. Conflict between Jason

and his mother grew, and he went to live with a family who had befriended him over the years. It quickly became apparent to the family that if Jason

was to complete his senior year in school and have any hope of a normal, productive life, he would need intensive counseling as well as an evaluation

for a possible learning disability. Jason fought with his peers in school, talked back to teachers, and had trouble concentrating. He had never read an entire

book; most nights he did not bring home any schoolwork claiming he had none. When the school fdy found his records, it turned out he still had

to take 2 years of English if he was to graduate; the school had him recorded as a sophomore, despite the fact that he was 18 years old.

Unfortunately, Jason had no health insurance other than Medicaid. Efforts to get him assistance through the local department of mental health were

met with claims, probably true, th.ac compared to other young mates in his city, Jason was doing well. He did not seem to be using or selling drugs, and

he was not under arrest. So no publicly funded counseling was available; and neither Jason’s mother nor his “adoptive” family could afford private

counseling. Similarly, Jason had apparently never received assistance through Education for All Handicapped Children Act progmms because no one

had ever identified him as having a learning or mental health problem. Jason was referred solely to an Alateem program (’group discussion sessions for

children of alcoholics). He became disenchanted with the group because it consisted primarily of much younger children and, for this and other reasons,

he soon dropped out.
Prevention of Adolescent Health Problems

A great number of efforts to prevent specific

adolescent health problems or (less commonly)

promote adolescent well-being have been designed

and implemented. Conclusions about their effectiveness are often difficult to draw, in large part because

few prevention interventions have been rigorously

evaluated. The performance of methodologically

sound evaluations appears to have been impeded by

a number of factors, primarily a lack of funding and

sensitivities concerning the discussion of some

subjects (e.g., sexual behavior, suicide) with adolescents. In addition, there are some important problems for which there has been little concerted

attention to prevention (e.g., violence). Further,

many preventive efforts consist of standardized

curricula, designed to be delivered by classroom

teachers, or other relatively passive measures such

as films, videos, brochures, and posters. While these

may provide important health-related information to

adolescents, it is unrealistic to expect these measures

alone to either engender much behavior change or

address the nonbehavioral aspects of adolescent

health concerns (e.g., subjective distress, physical

pain, family problems, school problems). Finally,

there has been relatively little specific attention to

efforts to promote well-being. For example, few

adolescents-especially those living in poor communities—appear to have adequate access to recreational and other opportunities to make developmentally appropriate and healthful uses of their discretionary time (37,61a,62,204,206,255).

There is a growing consensus (in some cases

accompanied by evidcnce from evaluations) about

the following:

●

●

●

Preventive efforts that change environments

(e.g., safety belts and airbags that provide

automatic protection in auto accidents), provide some form of concrete aid (e.g., contraception), or improve competencies (e.g., life-skills

training) are more effective primary prevention

strategies than are strictly didactic, educationbased interventions,

Preventive efforts that use comprehensive approaches involving multiple systems and addressing multiple issues may be more effective

than traditional single-issue, single-focus approaches.

In many cases (e.g., suicide, drug abuse), early

intervention with appropriate clinical services—

sometimes, but not always (189), termed secondary prevention—may be both more feasible

and more effective than primary prevention.

These too can be considered preventive interventions.

Education about the nature of health, health

problems, and health-related interventions is, of

course, important. Promising educationally based

preventive interventions appear to be those that are

both appropriate to the developmental and experiential level of the individual and participatory (i.e.,

encouraging guided discussion among adolescent

participants) rather than didactic. In addition, to be

consistent with findings from research on behavioral

change, it is important for health education efforts to

include explicit information about how adolescents

can secure health and related services. Various

groups’ recommendations concerning health education for adolescents are summarized in box C. Not

surprisingly, the promising elements of prevention

interventions are consistent with findings about the

elements of positive family life during adolescence:

t-hat it provide a prolonged protective and supportive

environment, in which power is gradually shared,

with the ratio between parental control and children’s autonomy slowly becoming weighted in the

direction of autonomy. It is possible to reorient

existing prevention efforts so that they reflect these

important principles.

Treatment of Adolescent Health Problems

If adolescent health problems cannot be prevented, then treatment services to cure or ameliorate

the adverse effects of problems should theoretically

be accessible, appropriate, and effective. To be

accessible, treatment services must be available,

approachable, and affordable. To be appropriate,

the services must be delivered in a manner appropriate to the developmental and experiential status of

the individual to be served. To be effective, services

must accomplish what they are intended to accomplish. Many U.S. adolescents in need of health and

related treatment services are likely to face problems

related to access and appropriateness. In addition,

treatment approaches for some highly visible problems—and for comprehensive approaches to health

care delivery—have not yet been demonstrated to be

effective.

Accessibility of Treatment—Access to basic

health and related services is a critical problem for

adolescents and appears to be related to the occur-
1-26. Adolescent Health--Volume I

Box C—Key Groups’ Recommendations on Health Education for Adolescents

Recognizing that most contemporary health education efforts are neither appropriate nor effective, several

different groups have generated suggestions for change. These include the Carnegie Council on Adolescent

Development Task Force on Education of Young Adolescents (29), the Centers for Disease Control within the U.S.

Department of Health and Human Services (153); and the National Commission on the Role of the School and the

Community in Improving Adolescent Health (153).

The different groups’ suggestions for change overlap a great deal, but each group emphasizes somewhat

different elements of a model strategy for health education. Furthermore, although none of the groups appears to

have made a concerted effort to select or reject specific topics in health education, each group does mention

somewhat different topics.l It is important to note that all three groups’ recommendations pertain to school-based

health education. To OTA’s knowledge, there have been no attempts to conceptualize comprehensive health

education for adolescents who are not in school.2

The recommendations of the Carnegie Council on Adolescent Development Task Force on Education of

Young Adolescents emphasize the following elements of a model strategy for health education:

. integrating health education into school environments that are health-promoting;

● intergrating health e&cation into the core instructional program as an element of the life sciences3; and

● training in the so-called life skills that help adolescents to resist interpersonal or media messages to engage

in specific negative behaviors, increase self-control and self-esteem, reduce stress and anxiety, gain in the

ability to express apprehension and disapproval, and become assertive (29).4

The Centers for Disease Control supports the concept of comprehensive school health, defined as follows:

1. a documental planned, and sequential program of health education for students in grades kindergarten

through 12;

l~e c~gie CO~Cil Task Fo~ specifkdly mentions growth and function of adolescent bOdieS during i3dOleSCeIICe; the wdue Of a

hdhful diet and exercise; the dangers of illicit drugs, alcoho~ and tobacco; and the avoidance of other risk behaviors (29). The Centers for

Disease Control supports education on ‘a range of categorical health problems and issues” and mentions as specific topics for health education

human immunodefkiency virus (HIV) infectio~ drug abuse, drinking and driving, emotional heal~ and environrnental pollution (153). ~

National Comrnission on the Role of School and Community in Improving Adolescent Health mentions disease and accident prevention, family

life and sex educatio~ drug and alcohol abuse, violence, mental heal@ and nutrition (153). Overall, howevez, the primary concern of the three

groups seems to be the approach to health education rather fhan specfic topics in health education.

2~e Cen@rs for Dis~ Control Ue charg~ with developing ~V-related CdUCMiOn preV~tiOn fOr OUt4f-SChOO] you~.

3Cme~e Cwmtion of New York is funding Stanford University to adapt for the middle grades its intertiSCiplirl~ appro~h to tie

postsecondary teaching of human biology; thus, a model curriculum will be available for implementation and testing.

4S~dents can learn titie essenti life skills through systematic instruction md mle-phying (29,83).

rence of many serious adolescent health problems. . adolescents whose only access is to urban

Some adolescents are more likely to be without public health clinics that appear unapproachaccess to health care than others: able;

●

●

●

the one out of seven adolescents without access

to health insurance (including the one out of

three poor adolescents without access to Medicaid44);

adolescents whose health insurance benefits do

not cover the services they need (e.g., adolescents who do not yet manifest full-blown

clinical mental health problems);

adolescents who are not aware of the existence

of services;

. adolescents in actual or potential conflict with

their parents about the receipt of health services

for which they must have parental consent;

. adolescents incarcerated in juvenile justice

facilities;

. homeless adolescents, living in families or on

their own;

● adolescents with multiple problems, who almost inevitably face gaps among service systems;

~Pwr adoIe~enN’ access to Medicaid WaS changed by the Omnibus Budget Reconciliation Act of 1990 (OBRA-90, Public Law 101-s08), which

required that beginning July 1, 1991, children born after Sept. 30, 1983, with family incomes up to 100 percent of the Federal poverty level, are to be

phased in to the Medicaid program. This change will no~ therefore, affect the current generation of adolescents.
Summary and Policy Options . 1-27

2. a curriculum that addresses and integrates education about a range of categorical health problems and issues

(e.g., human immunodeficiency virus (HIV) infection, drug abuse, drinking and driving, emotional health,

environmental pollution) at developmentally appropriate ages;

3. activities to help young people develop the skills they will need to avoid: a) behaviors that result in

unintentional and intentional injuries; b) drug and alcohol abuse; c) tobacco use; d) sexual behaviors that

result in HIV infection, other sexually transmitted diseases, and unintended pregnancies; e) imprudent

dietary patterns; and f) inadequate physical activity;

4. instruction provided for a prescribed amount of time at each grade level;

5. management and coordination in each school by an education professional trained to implement the

program;

6. instruction from teachers who have been trained to teach the subject;

7. instructions of parents, health professionals, and other concerned community members; and

8. periodic evaluations, updating, and improvement (153).

The National Commission on the Role of the School and Community in Improving Adolescent Health, a joint

project of the National Association of State Boards of Education and the American Medical Association,

recommended that young people receive a “new kind of health education--a sophisticated, multifaceted program

that goes light years beyond present lectures on ‘personal hygiene’ or the four food groups” and includes the

following elements:

● provides honest, relevant information about disease and accident prevention, family life and sex education,

drug and alcohol abuse, violence, mental health, and nutrition;

● teaches skills and strategies needed to make wise decisions, develop positive values, generate alternatives,

deal with group pressure, work cooperatively, and avoid fights—skills that are better learned through

role-playing and other small group participatory activities than through lectures;

● includes participation in physical activity programs that foster lifelong exercise habits; and

● begins before students are pressured to experiment with risky behaviors and continues throughout

adolescence. It should begin in kindergarten and continue in a planned, sequential manner through grade

12 (153).

SOURCES: Carnegie Council on Adolescent Development ‘Risk Force on Education of Young Adoleseenta: Carnegie Corporation of New

York, Carnegie Council on Adolescent Development, Task Force on Education of Young Adolescents, ?hrning Points.’ Prepating

Amem”can Yourhjbr the 2Jsr Cenrury (Washingto4 DC: June 1989); Centers for Disease Control and National Commission on

the Role of the School and the Community in Improving Adolescent Health: National Commission on the Role of the School

and the Community in Improving Adolescent HeaIti Code Blue: Uniting for Healthier Youth (Alexan&i% VA: Nlationai

Association of State Boards of Educatio~ 1990).

. adolescents in rural areas; eligible for Medicaid, because most juvenile justice

. Black, Hispanic, American Indian, and Alaska facilities are public institutions under the Medicaid

Native adolescents, because half of them live in definition, and Medicaid is prohibited from paying

families with incomes below 150 percent of the for health care provided in publicly funded instituFederal poverty level (approximately $13,000 tions. Many American Indian adolescents are urban

for a family of three in 1989). (and thus do not have access to the reservation-based

Indian Health Service’s services) and poor (and thus

Some of the major problems affecting adoles- most likely without private health insurance and

cents’ access to health and related services are listed perhaps without Medicaid). Homeless adolescents

in table 1. Barriers to access include poverty, lack of are particularly likely to be affected by financial and

insurance, lack of trained providers, limitations in legal restrictions on access.

coverage, lack of information about the availability

of services, lack of parental availability to accom- Appropriateness of Treatment—Even if adopany adolescents, and requirements for parental lescents do gain access to treatment services, the

consent or notification. Some adolescents are af- services may not be appropriate to their developfected by more than one of these barriers. Adoles- menta1 and experiential levels. Despite a longcents in juvenile justice facilities are typically not standing recognition by medical professionals that
Table l—Major Problems That Affect U.S. Adolescents’ Access to Health and Related Services

Estimated proportion and/or number

Problem of U.S. adolescents affected Adolescents most at risk

. . . . . . . Lack of financial access to services

Lack of health insurance:

● Living in poverty without Medicaid

. No private health insurance

Limitations in coverage:

● Limitations in coverage provided

by Medicaid

About 30 percent of poor adolescents do not have Medicaid

(approximately 2.76 million).

About 30 percent of all adolescents do not have private health

insurance coverage, but some (15 percent) have Medicaid or

other public (e.g., the Civilian Health and Medical Program of

the Uniformed Services) coverage. In 1988, 2.926 million

adolescents whose parent(s) worked were uninsured. a

Unknown. An estimated 3.70 to 4.58 million adolescents had

Medicaid coverage at some point in time during fiscal year

1988. b How many are affected by coverage Iimitations depends on the service needed, type of provider, setting,

adolescent’s State of residence, and whether service is sought

under Medicaid’s Early and Periodic Screening, Diagnosis,

and Treatment (EPSDT) program.

Poor adolescents in Southern and, to a lesser extent, Western

States are less likely to be Medicaid-eligible than poor

adolescents in other regions,

Adolescents in Southern (65 percent have private coverage)

and Western (54 percent have private coverage) States have

less private health insurance coverage than adolescents in

other regions.

A number of services are optional under Medicaid, and

adolescents in States that do not provide the service could

experience a barrier to access. Services that are optional for

States to provide to Medicaid beneficiaries include case

management; dental services; some diagnostic, screening,

preventive, and rehabilitative services; prescription drugs;

eyeglasses, prosthetic devices, dentures, and orthopedic

shoes; physical, occupational, and speech, hearing, and

language disorder therapies; services of psychologists, chiropractors, optometrists, and podiatrists; private duty nursing;

clinic services; intermediate care facility services; home and

skilled nursing facility care for children; inpatient psychiatric

facility care for children under age 21; and other medical or

remedial care recognized under State law. In 1989, however,

Congress passed EPSDT reforms that significantly expand

adolescents’ and other children’s access to Medicaid-covered

services by requiring States to periodically screen Medicaideligible adolescents for any illnesses, abnormalities, or treatable conditions and refer them for definitive treatment. States

also must cover treatment for conditions identified during an

EPSDT screen.

aln 1988, ~~ut 2.9= ~llljon “njnsur~ Us. ~ole=mts had parents who wo~~ sometime during the year; 2.&$5 million uninsur~ IJ.s. adole~ents had parents who WOrked fOr an empbyer

26 weeks or more during the year.

b~is estimate ~= +ve~op~ for OTA by the Of fim ~ the Actuary within the Health Care finanang Administration (HCFA) of DHHS (p~s), HCFA estimates that the average period of duration of

Medicaid coverage is 9 months. in contrast, data from the March 1989 Current Population Survey, a household-based survey of noninstitutional izad persons, found that 2.96 million adolescents

had Medicaid caverage only in calendar year 1988 (109). An additional 740,000 (23 to 25 percent of the 2.96 million) had both Medicaid and private coverage in 1988, acxxrding to the Current

Population Survey. (See ch. 16, “Financial Access to Health Services,” in Vol. Ill.)
Table l—Major Problems That Affect U.S. Adolescents’ Access to Health and Related Services-Continued

Estimated proportion and/or number

Problem of U.S. adolescents affected Adolescents most at risk

. Limitations in the coverage

provided by a private health

insurance plan

Lack of parental availability

Lack of independent legal access

to services

Lack of information about the availability

of health services

Lack of perceived approachability y/

appropriateness

Lack of appropriate care for adolescents

Unknown. Approximately 21.7 million adolescents (70 percent

of adolescents) are covered by private health insurance. How

many are affected by coverage limitations depends on the

service needed, type of provider, the limitations in any

particular insurance plan, and, to some extent, the adolescent’s State of residence.

About 60 percent (1 7.5 million) of adolescents ages 10 to 17

live in households where both parents (or their single parent)

work full time.

Unknown. How many are affected depends on combination of

age, health problem, type of service sought, and State of

residence.

Unknown, but available estimates indicate that the proportion

of adolescents affected is high (or that adolescents are in fact

correct that services are not available). For example, the

majority of adolescents in a national survey either were not

sure or did not believe they could obtain confidential treatment

for a sexually transmitted disease (STD) (when almost all

States allow services for STDs to be provided confidentially)

(lo).

Unknown, but available estimates indicate the proportion of

adolescents affected may be high. Adolescents disagree with

health care providers about what the most important health

problems are, about what should be discussed during health

care visits, and fear that private office-based physicians may

breach confidentiality.

Depending on the problem and the specialty, from 4d to 74e

percent of health care providers surveyed in the 1980s

perceive themselves insufficiently trained to treat specified

adolescent health problems. Primary care physicians appear

to have dlifficulty in identifying adolescents who have behavioral, emotional, and substance abuse problems.f

Adolescents in need of mental health care (especially those

adolescents without a diagnosable mental disorder), substance abuse treatment services, prenatal care (see below),

home health care, extended care facilities, preventive screening procedures, including contraceptive services, general

dental care, vision services, immunizations and inoculations,

routine physical exams, hearing, orthodontia and abortion

services.c

Adolescents below the age of majority (age 18 in most States)

and in actual or potential conflict with their parents about the

need for particular health services.

Unknown.

cForexamde at 1+< ~iqht stat- ~~ the Federal Employ-s ~alth Benefits plan have mandated some restriction of Private health Insuranca benefits foraborfions. Four ~at~ r~uire thatcover~

abortions be provided-but only on an optional basis and at extra cast.

din one stu~ of Midw~tern physiaans, g6 ~r~nt of o~tetrician~yn-logists felt ~omfortable addre~ing adolescents’ sexual concerns (compared to 54 percent of pediatricians and 50 pe~ent

of psychiatrists) (164).

eln one national mail sumey of primary care physicians (pediatricians, internists, and family practitioners), 74 percsnt of Internists reported training deficiencies in all 19 health problem areas

listed in the study. In contrast, greater proportions of family practitioners and pediatricians perceived having received adequate training, alt hough there were seven topic areas for which at least

50 percent of family practitioners felt insufficiently trained to handle, and similarly, eight topic areas for pediatricians. Six of the seven topic areas for family practitioners, and six of the eight

topic areas for pediatriaans, consisted of psychosocial, behavioral, and mental health concerns (21 ,22).

fThe number of physicians trained specifically in adolescent mediane is not known, but IS probably around 1,400 to 2,000, not all of whom are frontline health care providers; in addition, another 1,500

psychiatrists, 1,5oO psychologists, and 370 obstetrician-gynecologists have expressed specific interest in adolescent health issues. Except for traning of adolescent mediane specialists, criteria

for training in adolescent health care are vague, although improving (1 ,53).

Continued on next page
Table l—Major Problems That Affect U.S. Adolescents’ Access to Health and Related Services-Continued

Estimated proportion and/or number

Problem of U.S. adolescents affected Adolescents most at risk

Specific groups of adolescents or types of

adolescent problems

. Adolescents with private health

insurance in need of prenatal care

. Adolescents in juvenile justice

facilities

. Homeless adolescents

. Adolescents with or at risk of multiple

problems, who almost inevitably face

gaps among service systems.

● Racial and ethnic minority adolescents

. Rural adolescents

One-third of privately insured adolescents are not covered for

maternity-related services by their parents’ employmentbased health insurance plan. This problem affects about 3.6

million adolescent females.g

2 percent of adolescents (about 700,000),

Unknown, but DHHS estimated in 1984 (on the basis of 1976

data) that there were 1 million homeless and runaway

adolescents each year (256).

Unknown, because a complete assessment of the overlap of

health problems (especially environmental, physical, and

emotional, as opposed to behavioral) has not been conducted

(50,51,165). h Nevertheless, documented clinical experience

suggests that numerous adolescents who seek health services have more than one problem, and typically could receive

services from more than one health care or related “system”

(e.g., primary health care, mental health services, substance

abuse services, child welfare, shelters for the homeless)

(54,95,199).

Likely to be poor, and thus likely to be without health insurance.

More Iikely to be poor, and thus more Iikely to be without health

insurance.’ More likely to try to solve problems on their own

rather than seek help.j More likely to have problems gaining

physical access to health services because of lack of health

and mental health care providers as well as transportation

problems.

Homeless adolescents who are not emancipated, whose

parents cannot be reached, or whose parents will not give

permission for access.

Adolescents with one problem who are likely to have other

health problems include: adolescents with problem use of

substances (may have a mental health problem); adolescents

adjudicated to be delinquent (likely to have multiple health

problems); homeless adolescents (likely to have multiple

health problems); adolescents failing or misbehaving in school

(likely to become pregnant delinquent, and/or drop out of

school before graduation).

Black adolescents, Hispanic adolescents, American Indian

and Alaska Native adolescents, Asian-American adolescents.

But Hispanic adolescents are much more likely than others to

be uninsured regardless of family income (109).

Adolescents living on farms less likely to have help available

to them and more likely to try to solve problems on their own

rather than seek help, even though they are more likely to be

troubled.

9Approximately 21.7 million adolescents are covered by private health insurance. Approximately half of these (10.85 million) are estimated to be females (based on the male/female adolescent

population distribution). 3.6 million represents one-third of 10.85 million adolescents.

h~e admitt~~ rough ~timate is that 1 in 1() ado~~ents a~s 10 to 17(3 million) is “in dire straits, ~lin~ent, in trou~e in ~cIol, and prone to other high-risk bhaviors (e.g., IJlprOhChd SeXUd

intercourse, substanca abuse), and that another group of 4 million was “exfrernely wlnerable tothe negative consequences of [though notrrecess-”/yengaging in] multiple high-risk behaviors such

as school failure, substance abuse, and earty unprotected intercourse. . .“ (50). The 10 percent in the “direst straits” were initially judged to be so on the basis of having committed serious multiple

offenses, been multiple drug users, and been sexually active (50). Those behaviors are also associated, to some degree, with the other problem behaviors mentioned by Dryfoos (e,g., trouble in

school) (165).

itjke almost all other differen~s, mml-urban~uburban differences in health insurance disappear when differences in family income are taken into a-unt (1 m).

jlt is not known whether rural adolescents who did not seek help were extremely setf-reliant, undesirous of help, or unable to go and get help (323).

SOURCE: Office of Techology Assessment, 1991.
Summary and Policy Options . I-31

special skills and knowledge are required to treat

adolescents, there are few health care or youth

services professionals who have been specially

trained to treat adolescents. Approximately 1,400

primary care physicians are specialists in adolescent

medicine and only 1,400 psychologists express a

special interest in adolescents (less than one of each

of these professionals for every 1,000 persons ages

10 to 18); and there are approximately 5,000

psychiatrists specially trained to treat both children

and adolescents (8,60, 194,228). There is an American Society for Adolescent Psychiatry (1,500 members), and a North American Society for Pediatric

and Adolescent Gynecology (370 members) ( 142,191).

Other health professionals do not have special

interest sections or keep track of members especially

interested in adolescent health care. Unfortunately,

while the need for adolescent-specific training is

almost universally recognized, there are few training

programs, and the effectiveness of current training

criteria has not been systematically evaluated.

The most promising recent innovation to address the health and related needs of adolescents

is the school-linked health or youth services

center. Several private foundations, States, and

local governments have provided considerable resources to initiate comprehensive school-linked

health and/or youth services centers in which

adolescents are offered confidential services without

cost to the adolescents. Parental consent is usually

obtained on a blanket basis before the adolescent

seeks services.

45 A concerted effort is made at such

centers to select health professionals capable of

meeting the health and interpersonal needs of

adolescents.

A number of barriers-in particular, inadequate

funding, lack of trained personnel, community and

provider resistance, and lack of systematic data on

effectiveness—may interfere with successful implementation of comprehensive school-linked health or

youth services centers. There are, in fact, several

respects in which many school-linked health centers

can be improved upon, as is well recognized by those

who have worked closely with the centers (e.g.,

115). Currently, for example, many school-linked

health centers are similar to the mainstream health

care system in that they do not meet the needs of

students on holidays, weekends, and after school.

Photo credit: Office of Technology Assessment

The most promising recent innovation to address the

health and related needs of adolescents is the

comprehensive school-linked health or youth

services center for adolescents.

Some centers also are similar to mainstream health

services in that they do not conduct the kinds of

outreach that would attract more students (e.g.,

males (105)) or adapt services to the simultaneous

needs of students and the centers’ financial constraints (e.g., emphasize mental health promotion

and group counseling for students in addition to

individual counseling (2)), School-linked health

centers are limited by the inadequate numbers of

health care providers specially trained to work with

adolescents (see above), in multicultural settings,

and in an interdisciplinary fashion (15). Further,

adolescents who have dropped out of school typically do not have access to school-linked health

centers,

These shortcomings are not insurmountable. Accumulating evidence, and increasing levels of support, suggest that the second generation of schoollinked health and youth services centers may be able

to go much further than either the mainstream health

services system or the first generation of such

centers in meeting the health (and, perhaps, related)

needs of adolescents. Community-based health centers that provide confidential care appropriate to the

needs of adolescents could help meet the needs of

adolescents who cannot or do not choose to use

school-linked services.

Effectiveness of Treatment—Although it was

beyond the scope of this Report to conduct a

45s CC ch 15, ‘ ‘Major Issues Pe~ining to the Delivery of primary and Comprehensive Health Services to Adolescents, ’ in VO1. ~. Consent fo~s

often allow for parenls to refuse permission for specific services to be performed.
/-32 ● Adolescent Health-Volume I

full-scale evaluation of the effectiveness of treatment for every adolescent health problem, OTA

found that treatment for some of the more highly

visible problems+. g., treatment for alcohol, tobacco, and drug abuse and treatment for problems

associated with delinquency and homelessness—

has not been adequately assessed for effectiveness.

Some services (e.g., prenatal care for pregnant

adolescents, mental health care) may be known to be

efficacious under ideal conditions of use, but there

is little information about their effectiveness under

average or actual conditions of use.

What Is the Federal Government’s Role in

Improving Adolescent Health?

U.S. Executive Branch Agencies

U.S. executive branch agencies’ activities related

to adolescent health are numerous and varied:

●

●

●

●

●

●

●

monitoring adolescents’ health status and the

provision of services to adolescents;

supporting research;

helping to build the capacity to provide services

to adolescents;

financing services;

directly providing prevention and treatment

services 46

;

protecting adolescent health through the regulation of environmental risks to health; and

using the leverage of existing programs to

implement change.

Many executive branch agencies-from the U.S.

Department of Agriculture to the U.S. Department of

Transportation-play an important role in addressing adolescent health and related issues. The major

functions of some of these agencies are briefly

summarized in table 2.

Taken together, Federal agencies and the Nation

as a whole appear to spend considerable resources on

issues related to adolescent health and well-being. It

is difficult to define ‘‘considerable resources’ and

particularly difficult to determine whether Federal

agencies are spending ‘‘enough’ on adolescents or

any other group. As a percent of specific Federal

agency budgets, however, the amounts devoted

specifically to adolescents are typically small. Estimated adolescent-specific expenditures by Federal

agencies responding to a survey conducted by OTA

in 1989 are shown in figure 13. Within DHHS, it is

rare for an agency to devote more than 10 percent of

its expenditures specifically to adolescents. 47 I n

some Federal agencies outside DHHS, adolescent

issues may tend to receive a larger proportion of

appropriated funds, although the total dollar amounts

are small (see figure 13).48

The Federal Government is widely acknowledged

to play an essential role in research and health

monitoring, but relatively few research and health

monitoring efforts focus on adolescents. The National Institute on Child Health and Human Development, the lead agency for basic research in

adolescent health and development, estimated that it

devoted 6.6 percent of its fiscal year 1988 expenditures to adolescent issues .49 Little information about

the health status of adolescents is collected by the

Federal Government, and what is collected is

difficult to obtain and use. For further discussion of

these problems, see appendix C, “Issues Related to

the Lack of Information About Adolescent Health

and Health and Related Services.

Four other critical issues with respect to the

Federal role in adolescent health may be as important as the proportion of funds that the Federal

Government spends on adolescent health issues.

One is that most of the health spending related

to adolescents is on entitlement program s

%enerally speaking, the Federal Government does not currently play a major mle in directly providing prevention or treatment semices (see, for

example, C.D. Brindis and P.R. tie, “Public Policy Issues Affecting the Health Care Delivery Systems of Adolescents” (25)). One exception is the

provision of semices to American Indians and Alaska Natives by the Indian Health Service (in DHHS) and the Bureau of Indian Affairs (in the U.S.

Department of the Interior). However, the role of these agencies in adolescent health is smalt (228; see ch. 18, “Issues in the Delivery of Services to

Selected Groups of Adolescents, ” in Vol. III).

AT~e Catem for Dis~se Con@ol’s Division of Adolescent and School Health, the National Institutes of Health’s National Institute of Mlergy and

Infectious Diseases, and the Alcohol, Drug Abuse, and Mental Health Administration’s National Institute of Mental Health are the exceptions (with 100

percen~ 15 percenc and 12 percen4 respectively, of expenditures estimated to be for adolescents).

48To@/ F~e~ Ouflays in 19gg wtie $1.1 trillion (318). ~ this, $533 bfilion wm for ‘ie “human resources” programs that account for the

preponderance of the adolescent-health-related expenditures of the Federal Government (318). Figure 13 suggests that perhaps 2 percent of the $533

billion was spent on adolescent-spec~lc issues.

4~e Natlo~ ~sti~te on ~fid H~~ and Hum Development devot~ SNM p~cen~ges from 1979 to 1988 (297). III late IWO, however, the

agency began to design a separate adolescent program (3).
.

Summary and Policy Options . 1-33

(n

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. . .

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. . .

. . .

. . .

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57”
Table 2—Primary Functions of U.S. Executive Branch Agencies With a Role in Adolescent Healtha—Continued

Agency Primary function(s)

—Division of Injury Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Administers and directs programs on the prevention and control of intentional and unintentional

injuries.

—Division of Birth Defects and Developmental Disabilities. . . . Administers programs directed toward determining the environmental causes of selected adverse

reproductive outcomes and perinatal and childhood disabilities.

. Center for Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Directs a national program aimed at improving the identification, investigation, diagnosis, prevention,

and control of infectious diseases.

—Division of HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conducts studies, develops guidelines, evaluates programs and disseminates information on the

prevention of human immmunodeficiency virus (HIV) infection and acquired immunodeficiency

syndrome (AIDS).

. Center for Prevention Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Directs national programs of assistance involving preventive health services to State and local health

agencies.

—Division of STDs and HIV Prevention . . . . . . . . . . . . . . . . . . . . . Administers programs, in cooperation with other CDC components, for the prevention and control of

sexually transmitted diseases (STDs), including HIV infection.

-National AIDS information and Education Program . . . . . . . . Disseminates information about HIV infection and AIDS to the public through various means (mass

media, national information hotline, and clearinghouse).

. National Center for Health Statistics . . . . . . . . . . . . . . . . . . . . . . . . Collects, analyzes, and disseminates health statistics on activities that relate to health status, needs,

and resources.

C. Health Resources and Services Administration (HRSA) . . . . . . . Oversees a number of programs on general health services and resource issues relating to access,

equity, quality, and cost of care; helps coordinate government and private efforts on behalf of rural

health facilities.

● Bureau of Health Care Delivery and Assistance . . . . . . . . . . . . . Supports States and communities in their efforts to plan, organize, and deliver health care services

to medically underserved populations, and to special services populations such as migrants and

homeless people. Administers the National Health Service Corps Program.

. Bureau of Health Professions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Undertakes efforts to improve the education, distribution, and quality of health care professionals in

the United States.

. Bureau of Maternal and Child Healthc

. . . . . . . . . . . . . . . . . . . . . .Supports States and immunities in their efforts to plan, organize, and deliver health care services

to mothers and children. Awards maternal and child health block grants to States and

discretionary grants for developing models of health are delivery to mothers and children,

including adolescents.

D. Indian Health Service (IHS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provides health services for American Indians and Alaska Natives.

E. National Institutes of Health (NIH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conducts and supports biomedical research into the causes, prevention, and care of diseases.

. National Cancer Institute. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conducts and supports research on the causes, prevention, diagnosis, and treatment of cancer.

. National Eye Institute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Research on the eye and visual disorders.

● National Heart, Lung, and Blood Institute . . . . . . . . . . . . . . . . . . . Conducts and supports research on the causes, diagnosis, prevention, and treatment of heart, blood

vessel, lung, and blood diseases. Conducts educational activities related to the prevention of

these diseases.

● National Institute of Allergy and Infectious Diseases . . . . . . . . . Conducts and supports research on the causes, characteristics, prevention, control and treatment

of a wide variety of diseases believed to be attributable to infectious agents, to allergies, or to

other deficiencies or disorders in the responses of the body’s immune mechanisms.

● National Institute of Arthritis and Musculoskeletal and

Skin Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Research on arthritis (including juvenile arthritis) and musculoskeletal and skin disorders (e.g.,

muscular dystrophies, acne).

. National Institute of Child Health and Human Development . . Conducts and supports multidisciplinary behavioral and biomedical research on child health and

maternal health, on problems of human development (e.g., mental retardation) and on family

structure. Supports research on new contraceptives and AIDS.

● National Institute of Dental Research. . . . . . . . . . . . . . . . . . . . . . . Research aimed at eliminating tooth decay and an array of other oral-facial disorders.

ctn I g90, the Bureau of Maternal and Child Health and Resourcas Development split into two separate bureaus: 1 ) the Bureau of Maternal and Child Health, and 2) the Health Resources Development

Bureau.
Table 2—Primary Functions of U.S. Executive Branch Agencies With a Role in Adolescent Healtha—Continued

Agency Primary function(s)

. National Institute of Diabetes and Digestive and

Kidney Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conducts and supports research into the causes, prevention, diagnosis, and treatment of various

metabolic and digestive diseases (e.g., juvenile diabetes, cystic fibrosis, sickle-cell anemia,

hemophilia).

● National Institute of Environmental Health Sciences . . . . . . . . . Conducts and supports research to understand the effects of chemical, biological, and physical

factors in the environment on health.

● National Institute of Neurological and Communicative

Disorders and Stroke (NINCDS)d 

. . . . . . . . . . . . . . . . . . . . . . . . . . Conducts and supports research on neurological disorders (e.g., head and spinal cord injury) and

stroke.

. National Center for Nursing Research . . . . . . . . . . . . . . . . . . . . . . Administers programs and research training programs aimed at promoting the quality of research in

nursing and patient care, including care for adolescents.

F. Office of the Assistant Secretary of Health (OASH) . . . . . . . . . . . . Aids the Secretary of Health with management responsibilities of the department.

. Office of Disease Prevention and Health Promotion . . . . . . . . . Supports and coordinates prevention programs within the Alcohol, Drug Abuse, and Mental Health

Administration, the Centers for Disease Control, the Food and Drug Administration, the Health

Resources and Services Administration, and the National Institutes of Health.

. Office of Minority Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ensures that DHHS funds are used to address minority health problems by organizing, and

assessing current programs for minority health problems; provides technical assistance to States

and local governments with respect to their efforts to address minority health issues. e

. Office of Population Affairs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carries out Public Health Service Act Title X and Title XX programs related to adolescent pregnancy,

family planning, and population research.

ACTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Administers several Federal domestic volunteer service programs, including VISTA, the Foster

Grandparents Program, and Student Community Service Projects.f

National Science Foundation (NSF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Supports research in science and engineering through grants to universities and other research

organizations.

U.S. Consumer Product Safety Commission . . . . . . . . . . . . . . . . . . . . . . Collects information on consumer-product related injuries, promotes research on the causes and

prevention of such injuries, develops voluntary or mandatory standards for consumer products,

and sometimes bans hazardous products.

U.S. Department of Agriculture (USDA) . . . . . . . . . . . . . . . . . . . . . . . . . . Administers a wide range of programs related to farms, nutrition, food, hunger, rural development,

and the environment.

1. Office a of the Assistant Secretary, Food and Consumer Services

A. Food and Nutrition Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Administers several programs to make food assistance available to needy people, including the Food

Stamp Program, the School Breakfast Program, the Food Distribution Program, and the Special

Supplemental Food Program for Women, Infants, and Children. Also gives grants to States for

disseminating nutrition information to children.

B. Human Nutrition information Service . . . . . . . . . . . . . . . . . . . . . . . . . Performs research in human nutrition; monitors food and nutrient consumption in the United States;

and disseminates information on nutrition.

2. Office of the Assistant Secretary, Science and Education

A. Extension Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Serves as USDA’s educational agency and is the Federal partner in the Cooperative Extension

System, a nationwide educational network that provides access to food- and agriculture-related

research, science and technology. Recent initiatives include programs on human nutrition, youth

at risk building human capital, and family and economic well-being.

din 1990, the National lnstit~e of Neurol~i~l ad ~mmuni=tive Disorders ad ~roke split into two separate institutes: 1 ) the National Institute of Neurological Disorders and Stroke, and

2) the National Institute on Deafness and Other Communication Disorders.

%ese were its functions prior to the passage of Public Law 101-527, which established separate funding for an Office of Minority Health in DHHS.

~hese were its functions prior to passage of the National and Community Service Act (Public Law 101-610).

Continued on next page
1-36. Adolescent Health-Volume I

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Table 2—Primary Functions of U.S. Executive Branch Agencies With a Role in Adolescent Healtha—Continued

Agency Primary function(s)

D. Office of Juvenile Justice and Delinquency Prevention . . . . . . . . Administers programs and policies intended to improve the juvenile justice system; assists

communities in responding to the needs of juveniles; assesses the factors that contribute to

juvenile delinquency; and informs practitioners about research findings and successful

interventions.

E. Office for Victims of Crime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carries out activities mandated by the Victims of Crime Act of 1984.

U.S. Department of Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fosters U.S. workers’ welfare, improves their working conditions, and promotes opportunities for

employment.

1. Employment and Training Administration . . . . . . . . . . . . . . . . . . . . . . . . . Has responsibilities related to employment services, unemployment insurance, and job training.

Administers the Job Training Partnership Act, which authorizes block grants to States for job

training programs for economically disadvantaged individuals and provides authority for the Job

Corps.

U.S. Department of Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Develops coordinated national transportation policies and oversees a wide variety of transportation

programs carried out by nine operating administrations (aviation, highway, railroad; highway

traffic safety; urban mass transportation, etc.).

1. Federal Highway Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Administers the Federal-aid highway program of financial assistance to the States for highway

construction and improvements, such as highway repairs and maintenance, which improve the

safety of the roads; exercises jurisdiction over commercial motor carriers in interstate commerce.

2. National Highway Traffic Safety Administration . . . . . . . . . . . . . . . . . . . Carries out programs and research related to the safety and performance of motor vehicles, and

related equipment.

SOURCE: U.S. Congress, Office of Technology Assessment, 1991, based on: National Archives and Records Administration, Office of the Federal Register, The United States Government

Manual 1990/91 (Washington DC: U.S. Government Printing Office, July 1, 1990),
I-38 ● Adolescent Health-Volume I

Figure 13—Estimated Adolescent-Specific Expenditures by U.S. Executive Branch Agencies Responding to

OTA’s 1989 Survey (dollars are in millions)

NIAAA $6.1

NIMH $55.9 I

//

CDC $61.4~

OSAP $32.8

\ / BHCDA/HRSA $67.5 c

II \ . OASH/OPA $54.6

/

OHDS

$530

— ASPE

$0.250

U.S. Department of ~ PHS

Health and Human Servicesa = ADAMHA

OESE $4,000’ OSERS $18.9

only)

(in PHS)

U.S. Department

of Education f

$4,018.90

$4,400.35 R Other DHHS

NOTE: Graphs are not drawn to scale. Differences in size are designed to provide rough estimates of differences in adolescent-specific expenditures only.

Key to abbreviations:

ADAMHA—Alcohol, Drug Abuse, and Mental Health Administration

ASPE—Assistant Secretary for Planning and Evaluation

BHCDA--Bureau of Health Care Delivery and Assistance

BMCH--Bureau of Maternal and Child Health

CCDPHP--Center for Chronic Disease Prevention and Health Promotion

CDC--Centers for Disease Control

CEHIC--Center for Environmental Health and Injury Control

CHAMPUS--Civilian Health and Medical Program of the Uniformed Services

ClD--Center for Infectious Diseases

CPS--Center for Prevention Services

DI--Division of Immunization

DTC--Division of Tuberculosis Control

ES--Extension Service

ETA-Employment and Training Administration

FNS--Food and Nutrition Service

FSA—Family Support Administration

HCFA—Health Care Financing Administration

HRSA—Health Resources and Services Administration

IHS--lndian Health Service

NAIEP--National AIDS Information and Education Program

NIAAA--National Institute on Alcohol Abuse and Alcoholism

NIDA--National Institute on Drug Abuse

NIH--National Institutes of Health

NIJ--National Institute of Justice

NIMH--National Institute of Mental Health

NHTSA--National Highway Traffic and Safety Administration

OASH--Offfice of the Assistant Secretary for Health

ODPHP--Office of Disease Prevention and Health Promotion

OESE--Office of Elementary and Secondary Education

OHDS--Office of Human Development Services

OJJDP--Office of Juvenile Justice and Delinquency Prevention

OMH--Office of Minority Health

OPA--Office of Population Affairs

ORHP--Offica of Rural Health Policy

OSAP--Office of Substance Abuse Prevention

OSERS--Offica of Special Education and Rehabilitative Services

OSH--Office of Smoking and Health

OTI--Office of Treatment Improvement

PHS--Public Health Service

SSA--Social Security Administration

~he following agencies within DHHSwere unable to provide OTAwith the amount spent on adolescents alone: Farnity Support Administration, Social Security

Administration, Indian Health Service, National Institute on Drug Abuse (ADAMHA, PHS), Office of Treatment Improvement (ADAM HA, PHS), Nationai AIDS

Information Education Program (CDC, PHS), Office of Safety and Health (CCDPHP, CDC, PHS), Division of Immunization (CPS, CDC, PHS), Division of

Tuberculosis Control (CPS, CDC, PHS), Office of Rural Health Poiicy (HRSA, PHS), Bureau of Maternal and Child Health (HRSA, PHS), Bureau of Health

Resources Development (HRSA, PHS), Office of Disease Prevention and Health Promotion (OASH, PHS), Office of Minority Health (OASH, PHS).
Summary and Policy Options . 1-39

U.S. Department

of Labor

$2,166.40

OJJDP $72.5

El

--- NIJ $4.2

U.S. Department

of Justice

$76.70

CHAMPUS (

o

U.S. Consumer

Product Safety

Commission

s 17.30

“\~’ ‘

U.S. Department

of Defense

$552.00

1 ’

ACTION

$16.13

ES $90.3

G

= FNS $7.10

U.S. Department

of Agriculture

$97.40

NHTSA O

U.S. Department

of Transportatlon~

$0.98

%hisfigure includes $33.3 million spent by the Division of Adolament and School Heatth (CCDFWP),$O.45 million spent by the Division of f?eprtiuctive Health

(CC DPHP), $23.7 million spent by the Division of STD/HIV Prevention (CPS), $0.525 million spent by the Division of HIV/AIDS (CID), $3.3 million spent by

Division of Injury Control (CEHIC), and $0.158 spent by the Division of Prevention Programs (CEHIC).

~hls figure inciudes expenditures by the Bureau of Health Care Delivery and Assistance only. Expenditures on adolescents by other subagencies (e.g., the

Bureau of Maternal and Child Health) within HRSA were not provided to OTA.

%hisfigure includes:$l 9.5 million spent by the National Cancer Institute, $0.148 million spent by the National Center for Nursing Research, $2.1 million spent

by the National Center for Research Resources, $15,4 million spent by the National Heart, Lung, and Blood Institute, $98.2 million spent by the National

Institute of Allergy and Infectious Diseases, $0.784 million spent by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, $25,1 million

spent by the National Institute of Child Health and Human Development, $26.6 million spent by the National Institute of Diabetes and Digestive and Kidney

Diseases, $1.3 million spent by the National Institute of Neurological Disorders and Stroke. All are estimates.

~his is a very rough estimate byOTA. The Office of Elementary and Secondary Education dispenses most of the funds that are spent by the U.S. Department

of Education. The Office has no specific line items for adolescents, because it distributes grants to schools and other organizations for various programs that

are not aimed at a particular age group. In 1989, the Office of Elementary and Secondary Education disbursed $6.6 billion for all activities. OTA’s estimate

is based on the assumption that 10- to 18-year-oMs are attending grades 5 through 12, which constitute 66.6 percent of elementary and secondary grades,

not including kindergarten. Two-thirds of $6.6 billion is $4.4 billion. Since the percentage of adolescents attending school is likely to be lower than the

percentage of younger children attending school, this estimate maybe too high. OTA estimates, therefore, that the office of Elementary and Secondary

Education spends about $4 billion on education of adolescents. However, this estimate does not take into account that the cost of adolescents’ education

may be higher than that of younger students (e.g. more highly trained teachers, more sophisticated lab equipment).

khis figure does not nclude spending bythefollowing off”kes within the U.S. Department of Education that also serve adolescents: Office of Bilingual Education

and Minority Languages Affairs, Office of Planning, Budget, and Evaluation, Office of Postsecondary Education, Offke of Vocational and Adult Education.

These offices were riot able to provide OTA with estimates of spending on adolescents.

9This is a very rough estimate by OTA. The figure was tabulated by using the following percentages on how many adolescents were served in the respect ive

programs: 43 percent of the participants in the National School Lunch Program are in grades 7 through 12; 24 percent of the participants in the Supplemental

Food Program for Women, Infants, and Children are pregnant, breastfeeding, or postpartum females underage 18; and 34 percent of participants in the Food

Stamp Program are between the ages of 15 and 17.

hThis figure does not inclub the Federal Highway Administration, which also serves adolescents.

SOURCE: Off Ice of Technology Assessment, 1991, based on various responses to the Offica of Technology Assessment’s 1989 questionnaire regarding

adolescent health initiatives, Washington, DC, 1989.
I-40 Adolescent Health-Volume I

(e.g., Medicaid, Civilian Health and Medical Program of the Uniformed Services) rather than on

discretionary programs (research, program development, some support for services).so For example,

Federal spending for adolescents under Medicaid

dwarfs spending in the National Institutes of Health,

the Centers for Disease Control, the Alcohol, Drug

Abuse, and Mental Health Administration, and other

DHHS agencies combined (figure 13). 51 Second,

even some of the discretionary spending is in the

form of block grants to States.52 Unless discretionary spending is increased, or moneys are reallocated

from other population groups or health concerns,

these approaches to funding for adolescent health

potentially leave Congress and the U.S. executive

branch relatively little flexibility in spending for

adolescent health .53 Third, much of the Federal

non-block-granted discretional spending on adolescent health issues is devoted to a limited range of

specific topics and to a particular perspective on the

causes of adolescent health problems .54 The focus is

overwhelmingly on nonenvironmental approaches

to changing adolescents’ behavior. Although no one

would argue that there are certain behaviors in which

adolescents should not engage, there is little emphasis in Federal programs on viewing problems from

the perspective of adolescents, improving social

environments 55 in order to potentially effect change

in adolescent behavior, or improving adolescents’

access to health services. The fourth issue is that, as

this problern-specific approach suggests-and OTA’s

analysis of Federal policies confirms-the Federal

Government does not have a coordinated approach

to adolescent health. While there are numerous

coordinating bodies and memorandums of interagency agreements within the U.S. executive

branch, these coordinating efforts have not resulted

in a synchronized approach to adolescent health that

would prevent both excessive fragmentation and

unwarranted duplication of effort.

Congressional Committees

The fragmented and problem-specific approach of

U.S. executive branch agencies is understandable, at

least in part, as a reaction to the multitude of

congressional committees with a potential role in

adolescent health. As intended by the U.S. Constitution, executive branch agencies take their direction

from the legislation enacted by Congress. As shown

in table 3, numerous congressional committees and

subcommittees do or can potentially play a role in

the many facets of improving adolescent health.

Two congressional committees and subcommittees play a major role in authorizing legislation

related to adolescent health:

. the Senate Committee on Labor and Human

Resources and its Subcommittee on children,

Family, Drugs, and Alcoholism; and

. the House Committee on Energy and Commerce and its Subcommittee on Health and the

Environment.

Other congressional committees and subcommittees

have important roles in various topic, special population, or service delivery areas (e.g., the Senate and

House Committees on Agriculture authorize nutrition programs and rural development programs that

have the potential to affect the lives of rural

adolescents; the Senate Finance Committee is a

major actor in Medicaid legislation). As in the U.S.

executive branch, certain congressional committees

m~nr~f~emenr~ me ~efits ptid out auto~icdly each year to all who qua@ unless there is a c-e in @erl@g ~w; ~e~ ~clude F~e~

employee retiemcmt benefits, Medicare, Medicaid, unemployment compensation Aid to Families With Dependent Childreq and supplemental security

income (218). Congress can influence spending for entitlements by changing program eligibility and benefit rules; spending for entitlements is also

affected by demographic and economic trends, and by the extent to which individuals seek services (e.g., under Medicaid). Discretionary programs are

those subject to the annual appropriations process.

slit is ~.~mt t. note tit gene~ ~d men~ hospital COStS accounted for about two-ftiths of ~tit~ M~c~d exFQdi~ for lo to

18-year-olds in 1988 (253).

52B/ockgrants me su of Fede~ tids allotted to State agencies (e.g., educatiou health) which may be passed onto local agencies. S@teS det@e

the mix of services provided and the population sewed and are accountable to the Federal Government only to the extent that funds are spent in accordance

with program requirements. Sometimes, however, set-asides are required for spedlc population groups.

ssBfiers t. c-e ~ -ent Pofici= ~~t~ to tie c~~t F~m~ deficit ~d r~entiy le~s~t~ lfii~tions on incr~s in domestic discretionary

spending are discussed below (see “Barriers and Opportunities to Change”).

540TA~s @ysis of Fede~ effo~ ~~ ~sp~t to adolescen~ suggests hat tie adol~~nt h~ti problems that currently receive the mOSt Federal

attention are problems related to adolescent sexuality, drug use, and, to some extent, delinquency (other than drug use) (see ch. 19, “The Role of Federal

Agencies in Adolescent Halt&” in Vol. III).

55A ~ocia{ enviromnt is tie aggre~te of SOcial and cultural conditions that influence the life of ~ individwd or COQUQtitY. Asp~tS of tie soci~

environment particularly important to adolescents include adolescents’ families, other adults with whom adolescents come in contact schools,

workplaces, recreational facilities, and the media.
Table 3—Congressional Committees With a Role in Adolescent Healtha

AP - Handles appropriations AU - Authorizes major program areas O = Oversight of programs

B = Sets funding guidelines A = Authorizes specific programs T - Jurisdiction over funding sources such as trust funds

Health and Financial Future

Congressional Work, related services access to competitiveness

committees and Schools and recreation, Special (delivery and health and defense

subcommittees Families education and fitness Nutrition groups access) services readiness Other

Senate committees

Agriculture, Nutrition, and Forest@ AU/O A/O

Nutrition and Investigations

Appropriations d AP/O AP/O AP/O AP/O AP/O AP/O AP/O AP/O AP/O

Armed Servlcese A/o A/o A/o

Banking, Housing, and Urban Affalrsi A/O A/O

Housing and Urban Affairs

Budget o 0 0 0 0 0 0 0 0

Commerce, Science, and Transportation@ AU/O AU/O

Environment and Public Worksh A/o AU/O

Flnancd T/O T/O AU/T/O

Social Security and Famiiy Poiicy

Health for Families and the Uninsured

Governmental AffairsJ o 0 0 0 0 0 0 - 0 AU/O

a~cept~ere noted, the ~ngre=ionai committ~s shown in this tabie are standing committees, s~~~”ng ~mmjffeesare ~mmittees that are permanent bodies of either the House or the Senate,

have responsibility for broad areas of legislation (e.g., agriculture), and are responsible for most of the legislation considered by Congress. The Senate has 16 standing committees, and the House

has 22 standing committees. Se/ectcorrrrnittees are committees created to study particular probiems or concerns (e.g., Seiect Committee on Chiidren, Youth, and Families). These mmmittees

make recmmmencfations but are usually not permitted to report legislation to Congress (the one exception is the Select Intelligence Committee). Joint committees are committees composed of

members from both the House and the Senate. The Joint Economic Committee is the only joint committee which has a policy role v. an administrative roie, and reports its findings to Congress.

b~ly su~ommittees that ~ai e~ensiveiy with legislation relat~ to adole~nt health are not~, A su~~~ifiee is an offshoot of a standing or joint committee and deals with a partklliar area

covered by the fuli committee. There are usuaily a number of subcommittees within a particular mmmittee. Members of the subcomm ittee are aiso members of the fuil committee. Subcommittees

hoid hearings and amend bilis relating to their particular topic area. The amendments must be voted on in the full committee before returning to the House or Senate floor.

~he Senate Agriculture, Nutrition, and Forestry Committee authorizes and exerases oversight over numerous programs administered by the U.S. Department of Agriculture, including food and

nutrition programs (e.g., the Food Stamp Program, school nutrition programs) and programs related to rurai development.

%efoiiowing subcommittees of the Senate Appropriations Committee deal with programs relevanttoadoie= ent health : Agriculture, Rural Development, and Related Agencies ;Commerce, Justice,

and State, the Judiciary, and Reiated Agencies; Defense; interior and Reiated Agencies; Labor, Heaith and Human Services, Education and Related Agencias; and Transportation and Reiated

Agencies.

eThe Senate Arm~ se~=~ ~mmitt~ authorizes and exercis~ oversight over numerous programs administer~ by the U.S. Department of Defense, including the Civilian Health and Medical

Program of the Uniformed Services (CHAMPUS), acivilian health and medical program for retirees andthespouses and dependent chiidren of active duty, retired, and deceased military personnel.

~he Senate Banking, Housing, and Urban Affairs Committee authorizes and exercises oversight over programs administered by the U.S. Department of Housing and Urban Development, including

public and private housing programs and community development block grants.

9The Senate timmerce, Science, and Transportation Committee authorizes and exercises oversight over programs administered by the U.S. Department of Transportation, including programs

related to highway and motor vehicle transportation safety.

hThe ~nate Environment and pu~ic wok ~mmittee authorizes and exercisesoversight over programs adm inister~ by the Environmental protection Agency that alieviate OrredUCX nOISe, Water,

and air poiiutlon.

i~e ~nate Finan@ Committee authorizes health programs under the Social Security Act, including Medicaid.

jl%e Senate Governmental Affairs Committee has jurisdiction over programs of the Census Bureau, and over the organization of Congress and the U.S. executive branch.

Continued on nexl page ●
Table 3-Congressional Committees With a Role in

AP = Handles arwro~riations AU = Authorizes major proqram areas

B = Sets funding guidelines A = Authorizes specific”pro@ms .

Adolescent Healtha-Continued

O E Oversight of programs

T = Jurisdiction over funding sources such as trust funds

Health and

Congressional

Financial Future

work, related services accass to competitiveness

committees and Schools and recreation, Special (delivery and health and defense

subcommitteas b Families education and fitness Nutrition groups access) services readiness Other

Judiciaryk AU/O AU/O

Labor and Human Resources AU/O AU/0 AU/O AU/O AU/O AU/O AU/O AU/O AU/O

Labor

Education, Arts, and Humanities

Employment and Productivity

Disability Policy

Children, Family, Drugs, Alcoholism

Select Committee on Indian Affairs o 0 0

House committees

Agrlcultural A/O AU/O

Conservation, Credit, and Rural Development

Domestic Marketing, Consumer Relations, and

Nutrition

Appropriations n AP/O AP/O AP/O AP/O AP/O AP/O AP/O AP/O AP/O

Armed Services” A/O A/O A/O

Banking, Finance, and Urban Affairs A/o A/O

Housing and Community Development . .

Budget o 0 0 0 0 0 0 0 0

Education and Labor AU/O AU/O AU/O A/O A/o AU/O

Elementary, Secondary, and Vocational Education

Health and Safety

Employment Opportunities

Select Education

kThe~nate Judiaav Committw authoriz= ad exerci~~oversight over prqram administered bythe us, Department of Justi~, inciuding C)ffice of Justice and oth~ programs reiatd tOJUVWlik

justice and delinquency prevention.

i~e ~nate ~~ra~ Human R=ou~s ~mmitt~ a~horiz~ ad exeru%s Oversightoverawide range of programs reiated to h~ith, ~u~tion, ia~r, and public welfare. It has jurisdiction OVer

the Pubiic Heaith Service Act, substance abuse programs, education programs, and numerous other programs reiated to children and famiiies.

me House Agriculture Gmmittee authorizes and exerdses oversight over programs administered by the U.S. Department of Agriculture, including food and nutrition programs (e.g., the Food Stamp

Program, schooi nutrition programs) and programs reiated to rurai development.

n~e follo~ng su~mmitt~s of the Hou% Committe on Appropriations deal with progr~s relevant to adoi~nt health: commerce, Just~e, and state, the Judiciary, and Related Agencies;

Defense; interior and Reiated Agencies; Labor, Health and Human Services, Education, and Reiated Agencies; Rural Development, Agriculture, and Related Agencies; and VA, HUD, and

Independent Agenaes.

%e House Armed Services Committee authorizes programs administered by the U.S. Department of Defense, including CHAMPUS (see Senate Armed SeMces Committee above).

PThe House Banking, Finance, and Urban Affairs Committee authorizes and exercises oversight over programs administered by the U.S. Department of Housing and Urban Development, inciuding

housing and community development programs.

%The House Education and Labor Committee authorizes and exercises oversight over a wide range of programs reiated to education, iaborstandards, human resources programs fortheeiimination

of poverty and the care and treatment of children (e.g., Head Start, community services biockgrants, juvenile justice and delinquency prevention, and programs for runaway youths), andjobtraining.
Summary and Policy Options . 1-43

I

77

t?

I
I-44 ● Adolescent Health—Volume I

(e.g., the House Select Committee on Children,

Youth, and Families) or groups (the Senate Children’s Caucus) have responsibility for oversight

(House Select Committee on Children, Youth, and

Families) or information dissemination (Senate Children’s Caucus), but have no authorization or appropriation jurisdiction. Thus, there is fragmentation in

the U.S. Congress that it might be helpful to reduce.

Table 4-Summary of Three Major Policy Options

Related to U.S. Adolescents’ Healthe

Major Option 1: Congress could take steps to Improve

adolescents’ access to appropriate health

and related services.

Major Option 2: Congress could take steps to restructure

and Invigorate the Federal Government’s

efforts to Improve adolescents’ health.

Major Option 3: Congress could support efforts to Improve

adolescents’ environments.

Major Policy Options

OTA’s analysis of U.S. adolescents’ health needs

suggest numerous opportunities for action at many

levels: Federal, State, and local governments and

agencies; the private for-profit and not-for-profit

sectors; parents; and adolescents themselves. OTA’s

analysis also suggests that a more sympathetic,

supportive approach to adolescents by policymakers seems warranted. The orientation to

adolescents taken during any action is as important

as whether an action is taken or its intensity. The

new, more supportive approach that OTA’s analysis

suggests is warranted is discussed below.

Also discussed are three major policy options for

Congress that OTA’s analysis suggests would both

demonstrate the Nation’s commitment to a new

approach to adolescent health issues and provide

tangible, appreciable assistance to adolescents with

health needs:

1.

2.

3.

taking steps to improve adolescents’ access

to appropriate health and related services;

taking steps to restructure and invigorate

the Federal Government’s efforts to improve adolescents’ health; and

supporting efforts to improve adolescents’

environments (see table 4). 56

Each of these major options involves numerous

potential strategies, which are presented in detail

below. The three major options and strategies cut

across the areas analyzed in this Report. Some of

them would benefit certain groups of adolescents, or

address specific problems, more than others.

The complexity of adolescent health issues, the

diversity of the U.S. adolescent population, the

structure of the existing health and related services

apossible strategies for implementing these OptiOflS are presented in table

5 (Major Option 1), table 6 (Major Option 2), and table 8 (Major Option 3).

SOURCE: Office of Technology Assessment, 1991.

system generally,57 and political and value considerations 58 all guarantee that there is no one simple

approach to achieving any of the goals reflected in

the major policy options. With each major option,

therefore, OTA presents a range of potential strategies for accomplishing the goal. (See tables 5,6, and

8 for summaries of the strategies associated with

each major option.)

A New Approach

Currently, adolescent health is often viewed in a

problem-specific manner, with the emphasis on a

relatively few highly visible issues. Further, as is

consistent with the current national approach to

health problems, much of the burden for improvements in health is placed on the individual adolescent (201,260). If only adolescents would stop

taking drugs, stop having sex, and stay in school, the

argument goes, all would be right in adolescent

health. Parents, schools, health care systems,

individual health care providers, youth services

workers, and adolescents themselves are generally given little guidance, and few resources, to

enable them to be supportive of adolescents.

How do adolescents feel about adolescent health?

Part of the problem in answering this question is

that--despite the fact that they are held largely

responsible for their health problems—there is little

systematic evidence on the adolescent perspective

on health issues. The evidence that is available

suggests that adolescents believe that there is

considerable social ambivalence when it comes to

adolescent behavior such as sexuality, alcohol,

tobacco, and drug use, and other risk-taking behav-

~In addition to these major policy options, problem-or system-spec~lc policy options are presented below in Conjunction with findings from s~~lc

chapters in this Report (see ‘‘Specific Findings and Policy Options’ ‘).

sTSee smtjon &IOW entitled “Barriers and Opportunities to Change. ’

~sSee below, “Barriers and Opportunities to Change. ”
Summary and Policy Options .1-45

iors (e.g., dangerous driving practices) (235),59 that

many adults do not really care about them (209),@

that health care providers do not discuss the issues

of concern to them,61 and that many adults seem only

to see the negative when it comes to adolescents

(88).

These findings on adolescents’ views, scarce as

they are, suggest the existence of a wide gulf

between adolescents and adults. Adult observers

have also noted that public attitudes toward adolescents are, if not negative, then largely unsympathetic

(15,190). As noted by a work group of the 1986

DHHS-sponsored conference ‘‘Health Futures of

Youth, ‘ ‘ ‘ ‘most prominent among obstacles to the

creation and continuation of integrated community

health programs for youth is that the consumers of

these services are youth’ (15). An assessment of the

reasons for such unsympathetic attitudes is beyond

the scope of this Report,62 but the attitudes can be

characterized as consisting of notions that adolescence is merely a transitional stage, rather than a

period of life to be valued in its own terms (93), and

that adolescence is inherently a problem period

about which little can be done (70).

Adolescence is undoubtedly a difficult period for

many adults, especially parents (130). Both adolescents and adults may be unsure about how to deal

with shifts in the balance of power that begin to

occur during adolescence (130). The type of communication that adults have with adolescents, and either

the restrictions they place on them or the detachment

they assume, may be generated by caring, but may

not be perceived as benevolent by adolescents.

OTA concludes, therefore, that, in addition to

supporting concrete improvements in a broad

range of health and related services and policies,

Federal and other policy makers should follow a

basic guiding principle of providing a prolonged

protective and appropriately supportive environment for adolescents. Implementation of this basic

guiding principle may be difficult, however, and

attempts will undoubtedly generate disagreement

among policymakers. One model that could be

followed is that of authoritative parenting. Authoritative parenting consists of a combination of open

communication and give-and-take between parent

and adolescent, in an environment of consistent

support and firm enforcement of unambiguous rules.63

59 For exmple, OTA’S Youth Advisory Panel pointed out that while they are formally instructed to abstain from sex, drinking, ~d drugs, ~eY we

bombarded daily with contradictory messages from the adult-controlled media.

%e Umversity of Minnesota’s survey of 37,000 7th- through 12th-grade public school students in 86 Minnesota school districts found that only

about 45 percent of adolescents felt that church leaders cared about them, and that only about 41 percent of adolescents felt that ‘‘schoolpeople’ cared

about them (209) Perceptions that church leaders cared about them declined throughout adolescence, from approximately 50 percent of 7th graders

believing that church leaders cared, to between 27 percent (metropolitan area females) and 45 percent (nonmetropolitan-area males) of 12th graders

holding this bchef (209). (Respomes by grade were not reported for other categories of adults.) Overatl, however, about 70 percent of adolescents felt

that “aduf[s’ cared about them, and almost 90 percent felt that parents cared about them (209). However, only 65 percent of responding adolescents

reported that they felt that their family cares about their feelings, 50 percent that their families paid a lot of attention to them 45 percent that the people

m their farnilles understood them, and 45 percent that they had fun with their families (209). Between 13 percent (males) and 18 percent (females) felt

that they wanted to leave home quite a bit or very much (209).

61 See ch. 6, ‘ ‘Chronic Physical Illnesses: Prevention and Services, in Vol. II.

msorne negative attitudes towwd adolescents Meat last partially based in reality because some adolescents begin to engage in Socl~lY ~saPPrOv~

behaviors often more characteristic of adults (e.g., drug use, drunk driving, crime, out-of-wedlock pregnancy). However, because these behaviors are

not norrna(ive, they may gc( more attention (e.g., in the media) than similar behaviors by adults. Acting on the availability heuristic (207), observers

may tend to be believe that all adolescents, not just those reported on, are engaging in problem behaviors. In addition, as a function of their developing

cognitive abilities (see ch. 2, “What is Adolescent Health?” in Vol. II), adolescents typically begin to question and criticin tradition in ways that may

be uncomfortable for many adults (7 1).

~3,4s desmbed by Baumrind, ‘ ‘Aurhoriturivepurents, by definition are not punitive or authoritarian. They may, however, embrace traditional values.

Authoritative parents, in comparison to lenient parents, arc more demanding and, in comparison to authoritarian-restrictive parents, are more responsive.

Authoritative parents arc demanding in that they guide their children’s activities firmly and consistently and require them to contribute to family

functioning by helping with household tasks. They willingly confront their children in order to obtain conformity, state their values clearly, and expect

their children to respect their norms. Authoritative parents are responsive affectively in the sense of being loving, supportive, and committed: they are

responsive cogrutively in the sense of providing a stimulating and challenging environment. Authoritative parents characteristically maintain an

appropriate ratio of children’s autonomy to parental control at all ages. However, an appropriate ratio is weighted in the direction of control with young

children and in the direction of autonomy in adolescence. Authoritative parents of adolescents focus on issues rather than personalities and roles, and

they encourage their adolescents to voice their dissent and actively seek to share power as their children mature” (13).

In general, authoritative homes can be described as exhibiting a constellation of warmth, democracy, and demundingness. According to several

comprchemlve reviews of the literature on parenting practices and their outcomes, adolescents who grow up in authoritative homes score higher on

indices of psychological development and mental health (including self-image, social integration, and ability to make independent decisions) than do

adolescents from homes that arc predominantly permissive, rejecting-neglwting, indifferen~ or authoritarian (13,14,198). (Authoritan”an (as opposed

to authoritative) homes arc those in which parents are harsh, rigid, and domineering, and exert rigid social controls.) For further discussio~ see ch. 3,

“Parents’ and Families’ Influences on Adolescent Health, ” in Vol. II.
I-46 ● Adolescent Health—Volume I

However, even the execution of this model can

obviously be open to some interpretation.

OTA believes, however, that this principle can be

followed, though not without initial difficulty, from

the highest levels of Federal coordination, through

State, local, and school policy, to policies that

provide parents of adolescents with guidance and

time to spend with their adolescent children, to

efforts that attempt to teach social competence to

adolescents themselves. Adopting some or all of the

strategies suggested in the remainder of this Report

could also provide an indication that the Nation was

becoming more supportive towards its adolescents.

Major Option 1; Congress Could Take Steps To

Improve Adolescents’ Access to Appropriate

Health and Related Services

For a variety of reasons—adolescents’ lack of

financial or physical access, their need for confidential care and for providers who know how to work

with adolescents, the types of health concerns

experienced by adolescents (e.g., problems that may

not be deemed clinically serious, problems that

require intensive cognitive interventions, needs for

preventive services), and adolescents’ apparent lack

of knowledge about gaining access to services—

many American adolescents do not have effective

access to care in the primary or specialty health

services system or to related services.

Five general strategies Congress could pursue to

improve adolescents’ access to appropriate health

and related services are listed in table 5 and

discussed below. Each strategy would affect a

somewhat different aspect of access, affect somewhat different numbers and groups of adolescents,

and have different potential cost implications.*

Supporting the development of school-linked or

community-based centers that offer adolescents

comprehensive health and related services (e.g., care

for acute physical illnesses, general medical examinations in preparation for involvement in athletics,

mental health counseling, laboratory tests, reproductive health care, family counseling, prescriptions,

advocacy, and coordination of care; and, perhaps,

educational services, vocational services, legal assistance, recreational opportunities, and child care65)

(Strategy l-l) could potentially affect almost all

adolescents.

Improving adolescents’ financial access to health

services (Strategy 1-2)---even if effected in the

absence of comprehensive services----could touch

the many adolescents without financial access to

currently available health services (e.g., those adolescents with no health insurance; or with insurance

that does not cover essential benefits (e.g., early

intervention for family-related and other mental

health problems)).

Improving adolescents’ legal access to health

services (Strategy 1-3) would affect access to health

services for those adolescents who are on their own

or who may be (or perceive themselves to be) in

conflict with their parents on a particular healthrelated issue (e.g., sexuality counseling, need for

contraception, mental health, substance abuse).

The fourth strategy-improving the quality of

health care providers who work with adolescents

(Strategy 1-4)----would affect both the accessibility

and the appropriateness of care for almost all

adolescents who come in contact with a health care

provider, because many providers are not effective

at identifying needs or coordinating needed care.66

The fifth strategy to improve access-empowering adolescents to gain appropriate access to

health services by providing adolescents with important information about available health services

and by encouraging their participation in the design

and management of health services for adolescents

(Strategy 1-5)---would affect a broad range of

adolescents, particularly those who do not yet know

how to be, and whose parents are not able to guide

~NOte UMt the estimates of cost are. limited to short-ten-n (up-front) costs to the Federal Government and arc estimated extremely roughly and on a

relative basis (e.g., the cost of funding a group to devise a model statute that could provide more uniformity in consent and confidentiality requirements

affecting adolescents would be of much lower cost than FederaJ continuation funding for comprehensive school-linked health centers). More refined

cost estimates would depend on a wide range of factors to be decided upon should Congress decide to act upon any of the strategies spedied below

(e.g., for comprehensive service programs: the number of such programs funded, the number of adolescents expected to use the programs, the types of

services provided, the types of heatth care professionals used to provide the services; the types of financing mechanisms employed; the relative

contribution of Federat and local authorities). It was beyond the scope of the present Report to estimate such a wide range of potential costs.

~~Not all Semlces ~e available at all centers. Referral and integmtlon is an extremely important aspect of providing appropriate c~e for adolescents

(15).

‘See ch. 15, ‘ ‘Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Serwces to Adolescents, ” in Vol. UI.
Table 5-Strategies for Major Option 1: Congress Could Take Steps To Improve Adolescents’ Access

to Appropriate Health and Related Services

Access issue addressed — Rough estimate of

TIrne for (direct) cost to

Strategy Physical Legal Knowledge Affordability Approachability expected impact Federal Government

Strategy 1-1: Congress could support the development of centers that provide comprehensive and

accessible health and related services specifically

for adolescents In schools and/or communities.

1 -1a:

1-1 b:

1-1 c:

Provide Federal seed money for the development X

of school-linked and other community-based

centers that provide comprehensive health and

related services for adolescents.

Provide Federal continuation funding for already X

established school-linked and community-based

centers that provide comprehensive services for

adolescents.

Reduce existing barriers to the delivery of comprehensive services in adolescent-specific centers.

Strategy 1-2: Congress could take steps to improve

adolescents’ financial access to health services.

1-2a: Mandate an immediate expansion of Medicaid

eligibility for adolescents.

1 -2b: Mandate that employers provide health insurance for their currently uninsured workers and

those workers’ dependents.

1 -2c: Directly fund or provide incentives to States for

outreach to increase adolescents’ use of Medicaid benefits.

1 -2d: Discourage or prevent private insurers from implementing current plans to limit coverage of

adolescent dependents.

Strategy 1-3: Congress could take steps to improve

adolescents’ iegai access to health services.

1-3a: Encourage the U.S. executive branch or a nongovernmental entity to develop a model State statute

to enhance adolescents’ legal access to health

services.

1 -3b: Enact legislation that requires specific Federal or

Federal/State programs to adopt particular substantive policies with respect to parental consent

and notification.

1 -3c: Enact legislation conditioning States’ receipt of

Federal funds for specific purposes on the States’

having particular substantive policies on parental

consent and notification.

x x

x x

x

x

x

x

x

x

x

x

immediate and Could be high

long term

Immediate and Could be high

long term

Near term; study Medium

needed

immediate Depends on

utilization

Immediate None

immediate Medium

immediate and None

long term

Medium term Low

Immediate Low

Medium term Low

Continued on next page
Table 5-Strategies for Major Option 1: Congress Could Take Steps To Improve Adolescents’ Access

to Appropriate Health and Related Services-Continued

Access issue addressed Rough estimate of

Time for (direct) cost to

x x Immediate Low

Strategy Physical Legal Knowledge Affordability Approachability expected impact Federal Government

Strategy 1-4: Congress could increase support for x x x Immediate and High

training of health care providers who work with long term

adolescents.

Strategy 1-5: Congress could take steps to empower ‘

adolescents to gain access to health services.

1-5a: Encourage efforts to educate adolescents, parents, health care providers, and others who may

identify adolescent health problems and make

referrals, about legal and other aspects of using

health services.

1 -5b: Provide incentives for or mandate adolescent x Medium Low

participation in the design of programs and

research that affect adolescents at the Federal,

State, local, and private level.

SOURCE: Office of Technology Assessment, 1991.
Summary and Policy Options . 1-49

them in how to be, informed consumers in the

fragmented U.S. health care system. Strategies to

empower adolescents would work only if services

were available, of course.

Strategy l-l: Congress Could Support the

Development of Centers That Provide

Comprehensive and Accessible Health and

Related Services Specifically for Adolescents

in Schools and/or Communities

Recognition that many U.S. adolescents’ needs

for access to health and related services are not being

met in the mainstream primary health care system

has impelled a variety of groups and individuals to

support the development of school-linked or community-based centers that offer comprehensive and

accessible services designed specifically to meet

adolescents’ needs for physical accessibility, approachability, confidentiality, and low or no cost.67

Most of these efforts are associated with schools

(school-linked health centers), a few have been

initiated by health care organizations (hospitals and

health maintenance organizations), and apparently

even fewer seem to be freestanding centers based in

communities. 68

Existing ‘ ‘comprehensive centers vary considerably in the extent to which they provide a full

range of health and related services for adolescents.

One group has recommended that school-linked

health centers provide, at a minimum, general

medical, family planning, mental health, and social

services ( 15), In addition, that group recommended

exploring methods to expand traditional health

services to include legal assistance, vocational

guidance, learning disabilities assessment and planning, nutrition counseling, prenatal care, drug abuse

assessment and counseling, and recreational opportunities, either directly or through community linkages. Some school-linked health centers provide

these and other ‘ ‘expanded services (e.g., child

Photo credt: © Peter Byron, Mom’s Plains, NJ

The defining feature of a comprehensive service center for

adolescents is the extent to which the center attempts to be

responsive to the specific needs of adolescents, for

example, by having staff members who are knowledgeable

about and caring toward adolescents.

care services and parenting education for adolescent

parents), 69

In general, the types of services provided, and the

structure of the service delivery system, seem to be

determined by a combination of the needs of

adolescents in a particular community, 70 funding

~7For fufier discussion, See ch. 15, ‘ ‘Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Services to Adolescents, ” in

Vol 111.

6.x~c ~r=, se number of ~omprehensil~e semlce centers designed specifically to serve the needs of adolescents is not known (see ch. 15, ‘ ‘MaJor ‘ss”es

Pertam]ng to the Delivery of Primary and Comprehensive Health Services to Adolescents, ‘‘ in Vol. ffI). Strategy 2-4 (below) addresses data collection

issues pertaining to health scrvlccs for adolescents

@or ~ discussion of services provided by exist]ng school-linked hdth centers, s~ ch. 15, ‘‘Major Issues Pertaining to the Delivery of primary and

Comprehensive Health Smv]ces to Adolescents, ” in Vol. ITI.

70Bo~ the Ro&.fl wood Johnson Foundation-funded ~chml-based clinics and tie state of New Jemey.funded school-ltied health centers required

documentation of extensive community involvement in planning for centers before such centers could be funded (136).
I-50 . Adolescent Health—Volume I

and staffing limitations, and political considerations. 71 Beyond the actual services provided, the

defining feature of a comprehensive service center

for adolescents is the extent to which the center

attempts to enhance adolescents’ access to health

care through mechanisms that are not typically

found in the mainstream health services system:72

●

●

●

●

free care or use of sliding fee scales73;

evening and weekend hours of operation74

;

guaranteed confidentiality of services;

employment of staff members who are committed to and enjoy helping adolescents; are

knowledgeable about adolescent development,

behavior, and health and social problems; and,

optimally, come to see themselves as advocates

for adolescents and actually serve as formal

case managers to work together with individual

adolescents to coordinate programs of care

(321),

All of these mechanisms address access problems

that affect adolescents particularly-for example,

lack of money to pay for services or transportation,

lack of convenient hours, concerns about confidentiality, and perceived lack of approachability of

mainstream services.

Systematic evidence for the effectiveness of

comprehensive service centers in terms of health

outcomes for adolescents is sparse because few

studies of such centers’ effects on health outcomes

have been conducted, and those that have been

conducted have not been methodologically rigorous.

Furthermore, a number of existing comprehensive

centers have limitations related to insufficient funding, insufficient availability of providers, and a

tendency to follow a ‘‘waiting model’ of health care

provision similar to that of the mainstream primary

Photo credit: © Randall Hagadom, Titusville, NJ

There is as yet Iittle systematic evidence that school-linked

or community-based comprehensive service centers for

adolescents improve health outcomes, but there is clear

evidence that such centers can improve adolescents’

access to the health and related services that are

likely to be needed by adolescents.

health care system.75 Nonetheless, there is convincing evidence that school-linked and community -

based comprehensive service centers for adolescents

can improve access to health and related services

needed by many adolescents.

Many schools, health care organizations, communities, and States that would like to offer adolescents’ accessible ‘‘one-stop shopping, ’ or better

integrated services, for their health and related needs

may not be able to establish school-linked or

community-based comprehensive service centers.

One reason is lack of funds. Several existing centers

are in a precarious financial situation and may either

71F~~~x~plq ~~~com~tle~ will obj~f t. ~v~ a school.link~ he~~ center~t dis~but~ con~cqtives; o&m wiu Objat to Wch a cxmter

prescribing contraceptives (to be obtained elsewhere in the community); others may object to such a center including any facet of family planning or

reproductive semices. Anecdotal evidence suggests that some school-linked health centers have been blocked entirely because of fears that they will

emphasize sexuality concerns; other school-linked health centers vasy in the extent to which they provide serviees related to adolescent sexuality (see

ch. 15, “Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Serviees to Adolescents,” in Vol. III).

72 See ch. 6, ‘ ‘Chronic Physicat Illnesses: Prevention and Service& ‘‘ in Vol. II, and in Vol. III, ch. 15, “Major Issues Pert aining to the Delivery of

_~d Compmhemive He~~ Semices to Adole~~@” ch. 16, “F~ci~ Access to H~~ s~ic=,” ch. 17, “consent and cofildcn~ty

in Adolescent Health Care Decisionrnaking, ’ and ch. 18, “Issues in the Delivery of Semices to Seleeted Groups of Adolescents. ”

i’~As noted in ch. 15, “hfaJor hSUeS Pe rtaining to the Delivery of Primary and Comprehensive Health Se!vices to Adolescents, ” in Vol. III, some

observers have expressed grave concerns that the use of sliding fee scales, or any fucial requirements, will reduce adolescents’ pereeived access to

semices.

TdEvemW and week~d hours are sometimes, but not always, an element of comprehensive senlce Centers for adol=cenw.

75 See ch. 15, “Major Issues Pertaining to the Delivery of Prirmuy and Comprehensive Health Services to Adolescents,” in Vol. III, for further

discussion. Some of these problems could be addressed through the provision of additional funding to existing centers.
.

Summary and Policy Options . /-51

have to close completely76 or fail to completely

implement their program designs (11 5).

Funding is not the only barrier to the establishment of comprehensive centers. The association in

the public mind of school-linked health centers and

services related to adolescent sexuality and pregnancy seems also to have limited the extent to which

such centers have been implemented (98, 154,168).

The threat such centers pose to organized medicine

is another potential barrier ( 140).77 To date, however,

the livelihoods of mainstream health care providers

have not been threatened by the implementation of

comprehensive service centers for adolescents, because most centers have been provided in schools

and communities where the most likely service users

do not have health insurance and thus have little

access to the mainstream health care delivery

system.

Congressional recognition of U.S. adolescents’

unmet needs for financially accessible and approachable health and related services and the

ability of adolescent-specific school-] inked and

community-based comprehensive service centers

to provide such services could help enormously to

make such centers more acceptable to the public.

Several States are beginning to implement schoollinked health centers, and this development may be

an indication that public opinion is shifting toward

support for the idea of offering adolescents comprehensive and highly accessible health and related

services. 78

To support the development of centers that

provide adolescents with comprehensive health and

related services, Congress could follow one or more

of three strategies: provide seed money for the

development of school-linked or other communitybased centers for adolescents (Strategy l-la), provide continuation funding for such centers (Strategy

1- lb), or reduce barriers to the delivery of comprehensive services in such centers (Strategy 1- 1c) (see

table 5).

Strategy 1-1a: Provide Federal seed money for

the development of school-linked and other comPhoto credit: Katherine Criss, New York, NY

To help improve U.S. adolescents’ access to appropriate

health and related services, Congress could provide seed

money or continuation funding for school-linked health

centers or other comprehensive service centers

designed specifically for adolescents.

munity-based centers that provide comprehensive health and related services for adolescents.

The Federal Government could provide seed

money for centers that provide comprehensive

health and related services for adolescents by

making grants to States, local governments, health

care organizations, schools, or community-based

private, not-for-profit organizations. Providing seed

money would assist those schools, health care

organizations, communities, and States currently

without adequate financial resources to begin implementing school- or community-based comprehensive, accessible health and related services centers

for adolescents.

It IS important to note, however, that the State of

New Jersey’s School-Based Youth Services Center

program found that merely proposing the provision

of time-limited seed money to communities for

support of comprehensive services was not sufficient to garner community interest (205). As a

general matter, schools and communities are not

likely to be interested in making the considerable

investment required to start up a comprehensive

76~or ~xilmple, f(lndlng frOm the R~~ wo~ JohnS~n Foundation for school-]ink~ h~lth centers is schedul~ to end in 1993. Sec ch, 15, ‘ ‘Major

Issues Pcrtalning to the Delivery of Primary and Comprehensive Health Services to Adolescents, ” in Vol. III, for discussion.

~-{see Ch 15. ‘‘ Major Iwues Pertaining to the Delivery of Primary and Comprehensive Iicalth Services to Adolescents, ’ in Vol III.

7~AS dcs~rl~.(j in ch ] ~, ‘ ‘Major Issues Pcrtainmg to the Delivery of Primary and Comprehensive Health Services to Adolescents, ’ In Vol. HI, the

States of Kentucky, Iowa, Florida, Ncw York. and Ncw Jersey are experimenting with providing comprehensive school-linked services to adolescents

to one degree or another Other local jurisdictions (Minneapolis; Pittsburgh; Cleveland; Washington, DC; Alexandn< VA) also provide support for such

Services ( I 40)
I-52 ● Adolescent Health—Volume /

program for service delivery only to have to

dismantle the program for lack of continuation

funding (see also 186). As described above, 79

Federal (as well as State, local, and private) support

for adolescent health services is condition-specific

and thus fragmented. The Door in New York City,

which is widely regarded as the prototype of an

integrated comprehensive service model for adolescents, is supported by more than 80 funding sources,

including Federal, State, and local public agencies,

private foundations, corporations, and individuals

(77). 80

Strategy l-lb: Provide Federal continuation

funding specifically for already established schoollinked and other community-based centers that

provide comprehensive services for adolescents.

Continuation funding for existing and future

comprehensive health services centers for adolescents could help to maintain the existence of, and

potentially strengthen, existing centers and (if seed

money is provided) assure new centers that their

initial intensive efforts will not be wasted, Continuation funding could be provided by Congress through

matching grants to States, local governments, health

care organizations, or schools. 81 Requiring local

evaluation and local matching grants for continuation funding (as well as for seed money) would help

to ensure local involvement, integration of existing

services, and lack of duplication.

Strategy 1-lc: Reduce, through legislation or

regulation, existing barriers to the delivery of

comprehensive services in adolescent-specific

centers.

Existing barriers to the delivery of low-cost

services to adolescents in school-linked or other

comprehensive adolescent service centers include

State Medicaid administrative barriers limiting or

prohibiting reimbursement for services delivered in

school-linked health centers. They also include

State, Medicaid, and private insurance restrictions

on reimbursement of nonphysician providers.82

Removing such barriers to the delivery of lowcost services to adolescents in school-linked or other

comprehensive adolescent service centers may be

the weakest approach to supporting accessible,

comprehensive services for adolescents, but still

may be a somewhat effective strategy for increasing

some adolescents’ access to health services.

Issues--School- or community-based comprehensive and accessible care especially designed to

meet the unique needs of adolescents is not a new

idea (144, 187). As noted above, several contentious

and longstanding issues have slowed the development of such services, although a growing sense of

the health care crisis among U.S. adolescents

(8,29, 153) is beginning to erode some impediments,

at least at the local level.

Two of the most important issues with respect to

the provision of care that can meet the needs of

adolescents for confidential, approachable, comprehensive, no- or low-fee services are the issues of

community and health care provider resistance.

Federal backing would go a long way toward

engendering public support for school-linked or

other comprehensive services for adolescents, but

Congress and the U.S. executive branch themselves

have public concern about services related to adolescent sexuality to contend with (168). One way for

Federal policymakers to help overcome local resistance to school-linked health centers would be to

require centers receiving Federal funds to follow the

current approach of gaining initial parental consent

to provide services to adolescent children, either

blanket consent or consent that excludes specified

services, Alternatively, the Federal Government

could either permit State or local grantees to exclude

the provision of all or some family planning services

(e.g., dissemination of contraceptives) from any

T9See smtion above entifl~ ‘ ‘what 1,s the Federal Government’s Role in Improving Adolescent Health?”

Importantly, the administration of The Door reports that it must make a special effort to obtain such funding and protect the professional staff from

the perennial threat of the demise of specific programs (77). As described in ch. 15, “Major Issues Pertaining to the Delivery of Primary and

Comprehensive Heahh Services to Adolescents, “ in Vol. HJ, staff also work to coordinate individually funded programs so that they work to benefit

individual adolescent Door ‘‘members. ’

RIAs discussed below, such continuation funding could eventually be applied for by programs Eceivhg Seed moneys.

SZOTA was unable t. find data describing private insurance limitations on nonphysiciam health care providers, but private insurers may have such

Limitations.
.

Summary and Policy Options . /-53 — —

federally funded program or could itself exclude

such services .83

Federal policy makers could encourage organized

medicine’s further acceptance of school-linked or

other comprehensive services centers for adolescents by providing sufficient funding for mainstream

providers to deliver services in such centers. Were

physicians to dominate the provision of care in

school-linked or community-based centers, however, this approach could unnecessarily increase the

cost of providing services because not all-perhaps

significantly less than all-adolescent health problems appear to require the direct services of a

physician. 84 Instead, cutting-edge adolescent medicine training programs (including those few funded

by the Federal Government) emphasize the necessity

of an lnterdisciplinary approach to providing services to adolescents, involving nurses, nursemidwives, nurse practitioners, psychologists, physician assistants, social workers, nutritionists, and

health educators.

85 Ensuring adequate referral mechanisms to care providers in the community should be

a sine qua non of a comprehensive approach to

adolescent health care, and should help to alleviate

mainstream health care providers’ fear about being

displaced. But confronting the range of financial,

legal, quality, and informational barriers that prevent many adolescents from obtaining access to

health services (Strategies 1-2, 1-3, 1-4, and 1-5,

below) is necessary to help provide a truly integrated

system of health care for adolescents.

Even some supporters of school-linked and other

centers that provide comprehensive health and

related services for adolescents fear the implications

of providing Federal support. One concern that

arises with Strategies 1-1a and 1-lb above (and, to

a lesser extent, to 1-1c) is that providing Federal

Photo credit: Zacchaeus Medical Clinic, Washington, DC

Federal policymakers could encourage organized

medicine’s further acceptance of school-linked or other

comprehensive service centers for adolescents by

providing sufficient funding to allow mainstream

providers to deliver services in such centers.

funding for school-linked and community-based

centers might lead to the entrenchment of the

existing comprehensive service model, with its

known limitations. To minimize this problem, it

would be essential for the Federal Government to be

~~~~e statement of the N~tion~l COnfemnce of Cathollc Bishops on school-based clinics suggests that either approach WOUld have the Possibility of

gaining the support of this organlzatlmr, In its 1987 position paper, the National Conference of Catholic Bishops acknowledged that the basic health care

needs of many young people ,are not bclng adequately addressed, and suggested that school-bawd clinics ‘ ‘that clearly separate themselves from the

agcndti of contraceptive advocates may provide part of an effective response to the health needs of young people’ (1 54). Although more tharr half of

the school-based health centers surveyed by the Center for Population Options in 1988-89 provided counseling on birth control methods (94 percent of

centers in high schools. and 71 percent of centers in junior high and middle schools), only 20 percent of all such centers actually dispensed birth control

methods (92) In general, school-linked health centers have moved away from an exclusive emphasis on pregnancy prevention,

~~ls i,s not to S:IYthata~oa~range of health care providers currently providing care in traditional SeltingS (e.g., priva!tl Off_lCes, general communitY

clinics) or potcnflally interested in adolescent clinics as alternat ivc settings should not be adequately paid for their services. During their evaluation of

six school-based cllnics, Kirby and WasYak observed that cost-cutting measures led to heavy staff turnover, which reduced the continuity of the

relationships [hat can be developed between clinic and students and, potentially, the clinics’ effectiveness ( 105). Although the topic has been studied

min]mally, the few studies that have been comiuctc{i, the remmks of trusteii observers and of adolescents themselves, suggest that the quality of the

interpersonal relationship between health care provider and adolescent is essential to maintaining ~dolesccnt involvement in health care (1 15, 122,225;

see ch. 1 S, ‘‘ Major Issues Pertaining to the Delivery of R=imary and Comprehensive Health Services to Adolescents,’” in Vol. HI).

85Sec ch 15, ‘ ‘Major Issues Pertaining to the Delivery of Primary anti Comprehensive Health Services to Adolescents, ’ in Vol. HI. As discussed in

ch. 15, issues of leadership an(i role ambiguity can be pervasive in programs that do attempt to deliver cart using an intcr(iisciplinary approach.
I-54 ● Adolescent Health-Volume /

flexible in providing Federal support for funding,

to provide technical assistance to communities

that wish to develop comprehensive services, and

at the same time both require and provide

support for rigorous evaluation of both the

process and the outcomes of funded comprehensive services centers. In essence, a feedback mechanism for the continuing enhancement of health and

related services for adolescents could be supported.

Other issues related to the development of new

school- or community-based centers designed specifically to be responsive to the needs of adolescents

include how to structure their services to be responsive to the needs of local adolescents and how to

avoid potential duplication of services. Both issues

can be addressed by ensuring that relevant community members (including adolescents) participate in

the design of the services so that they meet local

needs and do not duplicate, but are integrated with,

existing services. Models for obtaining local involvement exist (36,205), and any Federal grant

program could build in requirements for community

participation. Structuring support in the form of a

matching grant86 could help to achieve continued

local community involvement.

Two issues are particularly relevant to Strategy

1-1c (and perhaps to a lesser extent, to Strategies

l-la and l-lb87). One is that neither the full range of

Medicaid and private insurance restrictions nor the

number of comprehensive health services programs

affected by them is currently known. 88 A study,

perhaps by the General Accounting Office, specifying such limitations might be useful before Congress

took action. The second is that the expansion of

third-party payment as a source of funding for

adolescent-specific comprehensive services programs

may conflict with programs’ objective of being

responsive to adolescents’ desire for confidentiality.

Currently, parents, as the financially responsible

parties, are almost always required to consent to the

receipt of services provided to adolescents by health

care providers. Even when parents of adolescents are

not required to consent to health services, they

almost always receive notification from Medicaid

and private insurers that services have been rendered

to their dependent children.89 Further, some health

care providers have expressed concern that billing

for services adds an additional layer of complexity

that may reduce adolescent accessibility to services

(77). Any efforts to increase resources for adolescentspecific comprehensive health services through

additional third-party payment would have to be

carefully constructed.

Strategy 1-2: Congress Could Take Steps To

Improve Adolescents’ Financial Access to Health

Services

For most individuals in the United States, coverage by health insurance is essential for gaining

access to almost all health services. For almost all

U.S. adolescents, health insurance is a necessary

(though not always sufficient) element of access.

One out of seven U.S. adolescents lacks any form of

health insurance coverage (109).90 Many uninsured

adolescents are the dependents of parents who

work ,

91 but whose employment benefits do not

include health insurance. One out of three poor

adolescents does not have access to Medicaid.

There is accumulating evidence that private

insurers, concerned about the rising cost of health

care and health insurance, may cut back coverage for

adolescents and other dependents, for insurance

coverage as a whole, or for specific benefits.

~por ~xmple, the State of New JmWy r~iled a 25-permnt matching grant from the local community; the matching ~Mt could tie the ‘om o

f

physical space or the provision of services as well as cash (205).

87~e extent t. which thew issues ~e relevmt t. s~ate~~ l.la ad 1. lb depend on the OV~~l stmcture of financing for comprehensive adolescent

services.

88AS of 1989, five Stites ~mhibit~ M~i~aid ~a~ent for h~th ~~ices de]iv~~ in schools, even by physici~s. Smtes varied in the extent to which

they permitted Medicaid coverage for nurses and other health care providers acting under the supervision of a physician (except that visits under the Early

and Periodic Screening, Diagnosis, and Treatment program were not subject to limits). The Omnibus Budget Reconciliation Act of 1989 (Public Law

101-239) mandated State Medicaid coverage of certified pediatric and family nurse practitioners as of July 1, 1990 (see ch. 16, “Financiat Access to

Health Services, ’ in Vol. ffI).

8~xceptlom t. mew ~monplam ~WeNes, and ways that some comprehensive services centers have sought ~d ob~ined third-P~Y Payment

without impairing adolescent confidentiality, are discussed in chs. 15 and 16, in Vol. III.

~see also ch, 16, ‘‘Fi~ci~ Access to Health Services, ” in VOI. III.

glFor tie most pa adolescents’ immm= stims ~flmts that of their parents, but 19 percent of uninsured adolescents (862,000 adolescents) live

without their parents. The number who live without their parents and work at least 18 hours a week (and thus would be more directly affected by an

employer mandate) is smaller (169,000). See ch. 16, ‘ ‘Financial Access to Health Services, ” in Vol. III.
Summary and Policy Options . 1-55

.——. .— —

Congress could adopt several strategies to address

these financial access problems: mandate art immediate expansion of Medicaid (Strategy 1-2a), mandate that employers provide health insurance for

their uninsured workers and dependents (Strategy

l-2 b), fund Medicaid outreach efforts (Strategy

1-2c), and prevent private insurers from reducing

coverage benefits (Strategy l-2d) (see table 5).

Strategy 1-2a: Mandate an immediate expansion of Medicaid eligibility for adolescents.

One out of three (approximately 2.76 million)

poor adolescents is not covered by Medicaid. The

Omnibus Budget Reconciliation Act of 1990 (OBRA90, Public Law 101-508) included provisions for a

Medicaid expansion, but this expansion will not

affect the current generation of adolescents. The

number of adolescents potentially affected by a

Medicaid expansion would depend on the specific

terms of the expansion. 92 OTA estimated the effects

of a range of specific terms for a Medicaid expansion. If all adolescents living in families with

incomes up to 149 percent of the Federal poverty

level were included and the categorical requirements

of A id to Families With Dependent Children (AFDC)

were dropped (as required by OBRA-90), an estimated 2.7 million adolescents who are currently not

eligible for Medicaid could be covered.

Concerns about costs may lead States and Federal

policy makers to resist further Medicaid expansions.

The actual cost of a Medicaid expansion would

depend in part on whether such programs as

Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment program (EPSDT) and other early

interventions that are designed to detect and treat

health problems before they become serious, result

Photo credit: Office of Technology Assessment

Many uninsured adolescents are the dependents of

parents who work but whose employment benefits do not

include health insurance. A congressional mandate that

employers provide health insurance benefits to all

permanent employees who work 30 hours or more per

week would expand health insurance benefits to

2.55 million uninsured adolescents.

in long-term cost-savings to society, as they were

designed to do.93

Strategy l-2b: Mandate that employers provide health insurance for their currently uninsured workers and those workers’ dependents.

The number of adolescents affected by an employer mandate would depend on the specific terms

of the mandate. A mandate that employers provide

health insurance benefits to all permanent employees who work 30 hours or more per week would

expand health insurance benefits to 2,55 million

uninsured adolescents.94 95

‘

2As rro[cd in ch. 16, ‘ ‘Financial Access to Health Services, ’ in Vol. III, OTA estimated that an immediate expansion of Medicaid eligibility for

adolescents up to 100 percent of poverty that retains c-urrent Aid to Families With Dependent Children (AFDC) categorical requirements wouId cover

b2 1,000 ( 13.5 percent) of those adole~ccnts currently uninmmd; this kind of expansion would be a step backward from the expansion voted under

OBRA-90, which climina(cs categorical requirements. Congress could support an immediate expansion of Medicaid eligibility for all adolescents up

to I(N percent of poverty, dropprng all AFDC categon’cul requirements; OTA estimates that this expansion would cover 40 percent (1.84 million) of

uninsured adolescents. An additional 874,000 adolescents (19 percent of those who are uninsured) would be included if the income standard was raised

to 149 percent of poverty, and all AFDC categorical requirements were dropped, bringing the potential total to 2.71 million adolescents. Other options

(e.g., making adolescents up to 133 percent of the povefly level eligible for Medicaid), not examined quantitatively by OTA, are, of course, also possible.

y~It should ~ no(~, on the other hand, that many preventive and early intervention programs may in faCt ir’lCrCaSe Ove12dl h~th C= ~s~~eir

value I]cs m reduced suffering and, possibly, in increased productivity.

940TA estlmatcd t~t a covsslon~ mmdate rhat Cmployms provide hea]~ ins~ance &nefiL~ to all prmanent employ&s who work 30 ho~ or

more per week would expand health irumrance benefits to another 2.55 million uninsured adolescents (equal to 55 percent of those without health

insurance coverage in 1987). An additional 255,000 adole..cents (another 5.6 percent of those without health insurance coverage in 1987) would be

covered by changing the mandate to 18 hours per week. See ch. 16, ‘ ‘Financial Access to Health Services, ’ in Vol. III.

Y$some adolcscen[s covmcd by either of these two strategies would be covered under the other one as well. A combination of a Medicaid exP~ion

to 149 percent of poverty (with AFDC categorical requirements dropped) and an employer mandate for those employees working 18 hours or more per

week would cover 78 percent of uninsured adolescents. Those left uninsured would largely be dependents of the self< mployed.
I-56 ● Adolescent Health—Volume I

Just as there is State resistance to Medicaid

expansions, there is considerable employer resistance to a Federal mandate for employer coverage.

Much of the resistance stems from concerns about

costs. Many employers have claimed that they

would no longer be able to employ many of those

employees who currently work fewer than 40 hours

a week should there be such a mandate. OTA did not

evaluate the validity of these claims. An employer

mandate raises issues much more general than those

related to adolescents’ access to health services.

Strategy 1-2c: Directly fund or provide incentives to States for outreach to increase adolescents’ use of Medicaid benefits.

In terms of the range of services covered, Medicaid appears in many ways to be the ideal health care

coverage plan for adolescents. One example is the

far-reaching EPSDT benefit, which now requires

States to periodically screen Medicaid-eligible children and adolescents for any illnesses, abnormalities, or treatable conditions and refer them for

definitive treatment. Medicaid is then required to

cover the costs of arty needed treatment.96 However,

as also discussed in chapter 16, ‘‘Financial Access

to Health Services, ’ in Volume III, Medicaid has

many other limitations that may block the delivery

of services to those in need. Unfortunately, much of

the data on lack of adolescents’ effective access to

Medicaid is anecdotal.

Thus, the extent to which the adolescents who are

eligible for Medicaid are not served is not known.

Existing data are not very informative about the

extent to which Medicaid-eligible adolescents get

access to services:97

● the Health Care Financing Administration in

DHHS estimates that adolescents ages 10 to 18

accounted for 17.1 percent of Medicaid enrollees in 1988 (4.6 million adolescents), and

accounted for an estimated 6.9 percent of

Medicaid program costs; and

. in 1988, Medicaids per capita expenditures for

EPSDT screening for adolescents ($4 per capita

Photo credit: Dion Johnson, Washington, DC

In 1988, Medicaid’s per capita expenditures for screening

of adolescents under the Early and Periodic Screening,

Diagnosis, and Treatment (EPSDT) benefit were only

about one-third the per capita expenditures for

children under age 5.

for 10- to 14-year-olds and $3 per capita for

15- to 18-year-olds) were one-third the per

capita expenditures for younger children ($15

per capita for children under age 5).

Comparisons such as these may not be appropriate because the types of services needed by older

individuals covered by Medicaid (e.g., nursing home

services) are quite costly (175,253). However, these

and other data suggest that the Medicaid program

needs to do more to reach eligible adolescents if it is

to be more than just a passive insurance plan and

actually help those adolescents who are most in

need.

98

Strategy l-2d: Discourage or prevent private

insurers from implementing current plans to

limit coverage of adolescent dependents.

Some or all of the approximately 21.7 million

adolescents (70 percent overall) who are covered by

private health insurance are potentially affected by

~These and otier EPSDT reforms were enacted N part of OBRA-89. tient EPSDT I_IXJ uirements are described in ch. 16, ‘‘Financial Access to

Health Semces.’ in Vol. III. To OTA’s knowledge, a study of the extent to which States are implementing the OBR4-89 mandate to screen and treat

Mechciud-eligible chddren has not been scheduled.

Wne o~y data available ~ for 1988 ~d thuS prw~e the enactment of OBRA-89. Iri additiom available ~~ have ce~ shoflcoms m~-

tiom limitations m the Health Care Financing Administration’s (HCFA) data system (see app. C, ‘‘HCFA.S Method for Estimating National Medicaid

Enrollment and Expenditures for Adolescents, ” III Vol. III). Nevertheless, they are the only quantitative data available.

W1t IS ~pomt t. note tit gen~ ~d ~en~ he~th hospl~ co5t5 acco~ted for about ~o-flf~s of Medicaid expendiw~ for 10- to 18-year-olds

m 1988 (253).
Summary and Policy Options . I-57

any such moves by private insurers. Congress could

perhaps require that adolescent dependents receive

the same benefits as the primary beneficiary.

An issue not addressed by requiring employers to

maintain existing levels of coverage is that some

adolescents with private insurance do not have the

benefits they need to gain access to health services

(e.g.. preventive services, contraception. prenatal

care. mental health services, substance abuse treatment, basic health services for adolescents in

juvenile justice facilities). An option addressing the

issue of benefits for adolescents under private health

insurance policies is included under ‘ ‘Specific

Findings and Policy Options’ for chapter 16, below.

Previous attempts by States to mandate that

private insurers provide benefits or coverage have

resulted in employers turning to ‘‘self-insurance"99

;

additional mandates or requirements may accelerate

this trend. Under the terms of the Employee Retirement and Income Security Act (Public Law 92- 104),

it IS unlikely that the Federal Government can pass

requirements that would affect self-insured plans.

Further. employers and private insurers may have a

point when it comes to restricting certain benefits:

for example. there is little evidence for effectiveness

of substance abuse treatment for adolescents or for

the more expensive settings for mental health

treatment. However, it seems unfair to restrict only

some groups from gaining access to such treatments

and settings.

Strategy 1-3: Congress Could Take Steps To

Improve Adolescents’ Legal Access to Health

Services

The body of law that determines the extent of

adolescents’ involvement in decisions about their

own health care is large and complicated because it

is an amalgam of common law, State and other

statutes, Supreme Court decisions, the decisions of

other Federal and State courts, and regulations

issued by government agencies.100 From the standpoint of adolescents, their parents, and health care

providers, among others, the law in this area is often

unclear and inconsistent.

The common law rule, based in part on the

assumption that children and adolescents are incapable of making mature decisions about their health

care, is that adolescents’ parents must give their

consent for medical or surgical services provided to

a minor child.101 There are a multitude of exceptions

to this rule, however, most of which are contained in

State laws. States can modify the age of majority to

confer on minors rights normally reserved for adults,

and five States have enacted statutes that specifically

authorize minors who have reached a designated

age—ranging from 14 to 16-to consent to health

care.

102 Furthermore, virtually al States allow all or

some minors (e.g., those age 12 or 14) to obtain care

for STDs without gaining their parents’ consent.103

Most States do not require that adolescents’ parents

be notified when adolescents obtain STD services,

but about one-third of the States allow parental

notification at the discretion of the health care

provider. State laws governing minors’ access to

mental health services, services for drug and/or

alcohol abuse, and other services vary widely across

problem areas, and this may be appropriate. Among

States, and even within a given State, however, the

laws frequently seem to lack any coherent rationale.

Restrictions on access to family planning and

abortion services by adolescents are ultimately

governed by Federal constitutional law as interpreted by the U.S. Supreme Court, and this law is in

flux. Health care provider organizations’ guidelines

regarding consent and confidentiality in the provision of services to adolescents are often ambiguous,

WA ‘ 1 self. ~s~ed’ plan is a heal~ &nefit plan m which the financial risk for provided medical services 1S assumed by the empklyti or Spomor. From

the time of the enactment of the Federal legislabon that exempted self-insured plans from State mandates in 1974 to 1987, the percentage of employees

covered by a self-inmred, employer-sponsored conventional health plan rose from about 5 percent to nmrly 60 percent. See ch. 16, ‘ ‘Financial Access

to Health Smwxs, in Vol. III.

l-sbody of law is s ummarized inch. 17, ‘‘Consent and Confidentiality in Adolescent Health Care Dccisiomnaking,” in Vol. III. For extensive

legal citatiom on laws pertaining to adolescent health care decisionmakmg, see J.D. Gittler et al., “Adolescent Health Care Decisionrnaking: The Law

and Public Po[icy ” (76).

Iolne age of majori~ is 18 m all States but Alaska, Nebm.sk% and Wyormng, wh~e it is 19.

IOzme five are Alabama, Kansas, Rhode Island, South Chrolim and @egon.

lo3As not~ in ch. 17, ‘‘Comsent and Confidentiality m Adolescent Health me kisio-ng, ‘‘ in Vol. XII, the terms used in these statutes vary.

Some statutes allow minors to consent to serwces for ‘ ‘sexually transmitted disease’ other statutes use the term ‘ ‘venereal disease, ’ or ‘‘‘infecdous,

contagious, communicable, and reportable diseases. ’
I-58 ● Adolescent Health-Volume I

and individual providers have been found to vary

considerably in their approach to these issues.l04

Some empirical evidence indicates that parental

consent and notification requirements may impose

barriers to some adolescents’ access to health

Services. l05 Specifically, adolescents in actual or

potential conflict with their parents may not seek

family planning services or even some other types of

health services (e.g., those related to sexuality,

substance use, and emotional upset) because they

fear parental involvement (76,127,333). Concerns

have also been raised that, as a concomitant of the

parental consent requirement, parents may be able to

‘‘voluntarily commit their adolescents to a mental

health or substance abuse treatment facility without

adequate safeguards to protect the rights of the

adolescent. l06

If it chose to, Congress could play a greater role

than it typically has in the past in the formulation of

public policies pertaining to the allocation of authority for adolescent health care decisionmaking. Two

issues that would arise if Congress were to consider

acting in this area are: 1) whether greater uniformity

and coherence in laws governing consent and

confidentiality in adolescent health care decisions is

desirable, and 2) if so, what substantive policies

should be adopted.

In the interests of increasing adolescents’ legal

access to services, substantive policies could be

changed to allow adolescents’ greater autonomy in

making decisions concerning their own health care.

A small body of relatively methodologically sound

research on the relationship between age and competence in health care decisionmaking suggests that

adolescents age 14 or older may be as capable as

young adults of making health care decisions

(5,18,103,104,1 19,120,327), challenging one of the

key assumptions that underlies requirements for

parental consent and notification. The evidence is

not as conclusive as one might like for policy

decisions, however, and adolescents’ capacity for

*

!.

,. II!P” , , . ti -. .

Photo credit: Sarah Hocut, Atlanta, GA

A few empirical studies suggest, though not conclusively,

that at about age 14 adolescents may be as capable as

young adults of making health care decisions. This

evidence challenges one of the key assumptions that

underlies legal requirements for parental consent.

making health care decisions is only one of many

important considerations in determiningg whether

adolescents should be able to consent to health

services or to receive services without parental

notification. 107 Other important considerations include the following:

the interest of the State in promoting public

health and ensuring that individuals have access to needed health services, in ensuring that

parents assume responsibility for their children,

in protecting family autonomy and privacy, and

in maintaining family cohesiveness and stability;

the interests of adolescents’ parents in ensuring

their children’s welfare, in maintainingg authority over their adolescent child, in protecting

their family’s autonomy and privacy, in directing the upbringing of their children, and in

104 s ee ~h. 15, ~ ~~jor Issues pex t. the Delivery of_ ~d Compreh-ive H~th Servi@s to Adolescent s,” and ch. 17, ‘‘Consent ~d

Cotildentiality in Adolescent Hezdtb Care Dezisionmakm“ g,” in vol. m.

IOSIt is not clw IIMI p~en~l notilcation requiremen~ are any less of a barrier to adolescents’ access than parental Consent KWfimentS.

KX@atient men~ he~th ~Wices pow s~i~ problem k the area of consent. About two-thirds Of SbteS k’e s~tuteS tit ~low P~en@* ~ a

wncomitant of the parental consent requirement, to make a “voluntary commitment’ to a mentat health facility of a minor child. ‘Ilmse statutes vary

substantially in the safeguards they provide against inappropriate hospitalization or institutionalization to manage “troublesome” minor children who

mRy not have severe mental health problems (326).

IOTB=use tie e~s~ litem~e on ~oleXen~’ ~pacity to Consent is not conclusive and is focused mostly on white, mid~~cl~s adolescents, the

option of funding additional studies on this topic is presented in table 24 in the section entitled “Speci.flc Findings and Policy Options, ” below.
Summary and Policy Options . 1-59

●

being protected from financial liability arising

from the provision of health services to their

children; and

the interests of health care providers in providing services to adolescents that are consistent

with their professional ethics and professional

practices, in being able to receive compensation for their services, and in clear laws that

enable them to avoid unintentional violations

of those laws. 108

There are sound reasons for promoting parental

involvement in adolescent health care decisionmaking. As described in this Report, evidence suggests

that appropriate parental and family involvement

with adolescents is essential to adolescents’ optimal

development and functioning.l09 In some situations,

however, parents do not act in the best interests of

their adolescent children,110 and adolescents may

delay receiving appropriate health care services for

fear of parental involvement.

111 Three strategies for

improving adolescents’ legal access to health and

related services that Congress might want to consider are encouraging the development of a model

State statute (Strategy 1-3a), requiring specific

Federal or Federal/State programs to adopt particular substantive policies with respect to parental

consent and notification (Strategy l-3 b), and conditioning States’ receipt of Federal funds for specific

purposes on the States’ having particular substantive

policies with respect to parental consent and notification (Strategy 1-3c).

Strategy l-3a: Encourage the U.S. executive

branch or a nongovernmental entity to develop a

model State statute to enhance adolescents’ legal

access to health services.

Congress could encourage the U.S. executive

branch or a nongovernmental entity to lead in the

development of a model State statute that would

potentially enhance adolescents’ legal access to

health services by increasing their autonomy in

decisions about their health services. The model

State statute might be used to inform State policies

—.

Photo credit Center for Youth Services, Washington, DC

There are sound reasons for promoting parental

involvement in adolescents’ health care decisionmaking.

Available evidence suggests that appropriate parental and

family involvement with adolescents is essential to

adolescents’ optimal development and functioning.

regarding consent and confidentiality in adolescent

health care decisionmaking. This would be true even

if the statute were not adopted in its entirety by all

States.

Optimally, the development of a model State

statute would involve a variety of all relevant parties,

including parents, advocates for adolescents, thirdparty payers, community leaders, ethicists, experts

in informed consent, developmental and social

psychologists, historians of childhood and adolescence, health care providers, lawyers, and adolescents themselves. Relevant studies and testimonial

evidence, considered dispassionately and systematically, could be brought to bear.

The financial costs to the Federal Government of

funding a study group to develop a model State

statute would be relatively low, although any

IOSSee box 17.B, 1‘A conc~p~al Frmcwork To Aid public P~]ic~,&c~ in F~r-rnulatjng policy Related to ~C ,4]]oCatlon Of Authofity fr)r AdOIM~ent

Health Care Decisionmaking, ’ in ch. 17 in Vol. ITI,

l~gseveral approaches for incremlng supw~ for adolescents’ families are discussed in Strategy s-1 in Major OPtion q, below.

I Iosee Primarily ~h. 3, ‘ ‘Parents’ and Families’ Influence on Adolcscent Health’ in Vol. II, but also ch. 11, ‘‘Mental Health Problems: prevention

and Services’ ch. 12, “Alcohol, Tbbacco, and Drug Abuse: prevention and Services’ ch. 13, ‘ ‘Delinquency: Prevention and Services’ and ch. 14,

“Homelcssncss: Prevention and Services, ’ in Vol. III.

11 Isee especially ch. 9, ‘‘AIDS and Other Sexually Transmitted Diseases: Prevention and Services, ’ in Vol. II, and ch. 17, ‘‘Consent and

Confidentiality In Adolescent Health Care Decisionmaking, ’ in Vol. III.
I-60 ● Adolescent Health-Volume I

improved access to health services by adolescents

might prove costly in the near term. 112 The potential

exists, however, that the model statute that is

developed could be: 1) more restrictive than what

currently exists in some States and case law, and so

further limit adolescents’ access to care; 2) so

unrestrictive as to inappropriately reduce parental

involvement in the parent-child relationship; or 3) so

nebulous as to be unhelpful.113 Nonetheless, the

legal barriers to access that adolescents in conflict or

potential conflict with their parents face as a result

of the present legal situation make taking the risk of

attempting to develop a model statute seem worthwhile.

To make their task more manageable, the individuals developing the model statute might want to

focus on developing model statutes in certain critical

areas, such as policies to permit confidential access

to mental health, drug/alcohol treatment services,

pregnancy-related services, contraceptive services,

and HIV testing and STD treatment services for a

broader range of adolescents; policies to eliminate

inappropriate ‘‘voluntary’ commitments of adolescents to inpatient mental health facilities by their

parents; and, possibly, policies to provide more

workable alternatives to parental notification for

abortion.

Strategy l-3b: Enact legislation that requires

specific Federal or Federal/State programs to

adopt particular substantive policies with respect

to parental consent and notification.

Congress authorizes and appropriates funds for a

variety of Federal and Federal/State programs that

provide adolescent health services or reimbursement

for such services, for example,

● Medicaid,

. the maternal and child health services block

grant program authorized under Title V of the

Social Security Act,

. the family plannin g program authorized under

Title X of the Public Health Service Act, and

. the alcohol, drug abuse, and mental health

services block grant program authorized under

Title XIX of the Public Health Service Act.

The Federal laws authorizing and appropriating

funds for these programs and the regulations and

rules issued by agencies administering these programs at the Federal level generally do not deal

directly with questions of whether adolescents must

have parental consent to participate in the programs,

whether parents must be notified of adolescents’

participation in the programs, or whether health care

records and communications between program service providers and adolescents are confidential vis-avis their parents.

114 In the absence of explicit

directives from Congress or Federal agencies, the

administrators of federally funded programs are

free-so long as they remain within the parameters

imposed by State law and Federal constitutional

law—to establish their own policies regarding

parental consent and notification requirements and

the confidentiality of records and communications

involving minors.115

Congress could enact legislation that requires

Federal and Federal/State programs that provide

health services for adolescents or reimbursement for

such services to adopt particular substantive policies

with respect to the allocation of authority for

adolescent health care decisionmaking. Enacting

legislation that requires Medicaid to increase adolescents’ autonomy in decisions about their health

services could help to improve access for poor

Medicaid-eligible adolescents. It could also signal a

new direction to other third-party payers in the

development of policies to permit confidential

access to mental health, drug, contraceptive, and

STD treatment services for a broader range of

adolescents; and policies to prevent inappropriate,

112st;e ~~ve for the ~Wen~ a5 yet ~pmvem but fike]y, tit ac~ss to some e~ly intervention wr-vices would be cost-saving in the long-term.

11 ~Such is ~gely tie Cme ~~ the et,hic~ s@temen~ on tis issue of sevad kdth care provider org animations. See ch. 17, ‘‘Consent and

Confidentiality in Adolescent Heatth Care Deeisionrn.akm“ g,” in vol. m.

114~ere ~ve ~n exceptions, for ~~ple a tie issued by DHHS in 1987, which prohibits feder~ly ~d~ ~cohol or drug abuse programs from

notifying a minor’s parent of the minor’s application for treatment without the minor’s consen~ but only in States where State law permits minors to

obtain alcohol or drug treatment without parental consent (42 CFR, Part 22.214 (1989)).

1151n 1983, D~S umuaess~ly ~ttempted t. pmm~gate re@ations r~x tit f~ly plxcticsr~ivixrg Federal fud under Title X

of the Public Health Service Act notify parents of unemancipated minor children where contraceptives were prescribed. These regulations-issued

pw suant to a congressional amendment to the authorizing statute for the Title X program that provided that ‘‘ [t]o the extent practicable, entities which

receive grants or contracts under this subsection shall encourage family ptiicipation in pro@ts assisted under this section (42 U.S.C sec.

300(a)(l 982)k-aroused a great deal of controversy and were the subject of litigation in the Federal courts. Ultimately, two Federal courts enjoined DHHS

from implementing the regulations.
Summary and Policy Options . /-67

involuntary hospitalizations of adolescents for mental health and substance abuse treatment.

Strategy 1-3c: Enact legislation conditioning

States’ receipt of Federal funds for specific

purposes on the States’ having particular substantive policies on parental consent and notification.

Exceptions to the common law requirement for

parental consent and legal provisions pertaining to

parental notification have generally been carved out

by State courts and legislatures, The extent to which

States currently allow minors to obtain services on

their own (i.e., without parental consent or without

either parental consent or notification) varies widely.

●

●

●

Most States already allow all minors (or minors

of a certain age, e.g., 12 or 14) to obtain

diagnosis and treatment services for STDs

(sometimes termed “venereal diseases” or

‘‘infectious, contagious, communicable, and

reportable diseases, ’ as noted above) without

parental consent. Nearly two-thirds of States

provide that STD services may be furnished

without parental notification; most of the others

give health professionals discretion to notify

parents.

Only a few States currently have statutes that

expressly authorize minors to consent to or

receive HIV testing without parental consent.

These laws vary with respect to parental

notification requirements (e.g., some give providers discretion; one State requires notification if the test is positive).

A little under half of States have statutes

providing that minors (or minors who meet

specified criteria) may obtain without parental

consent family planning services (variously

described as “contraceptives,” ‘‘birth control

services, ’ or “services for the prevention of

pregnancy”). Only a few of the State statutes

that permit minors to consent to family planning services without parental consent have

provisions pertaining to parental notification of

the minor’s application for receipt of such

services, and nearly all of them allow, but do

not compel, parental notification. 116

About one-quarter of States have enacted statutes requiring parental consent to abortion for

minors. Some of these State statutes have been

invalidated or are currently being challenged on

constitutional grounds, however, so not all of

the statutes are currently being enforced.117 A

little under one-quarter of the States have

statutes requiring parental notification of a

minor’s abortion decisional

Over half of States have statutes allowing

minors to consent to pregnancy-related services (e.g., testing to determine pregnancy,

prenatal care, and delivery services). Most of

these statutes do not require parental notification. About one-fourth of the States have

statutes that provide for parental notification at

the discretion of health professionals.

All but five States (Alaska, Arkansas, Oregon,

Utah, and Wyoming) have statutes specifically

authorizing minors to consent to services related either to treatment for drug abuse, to

treatment for alcohol abuse, or to treatment for

both drug and alcohol abuse. Some of these

statutes apply only to minors who have reached

a designated age, ranging from 12 to 16 years

of age. The various statutes exhibit considerable variation when it comes to parental notification provisions.

1 lb~e US, Supreme COW I-ul~ in Carq v. PC@ation Sem”ces international (431 U.S. 678 (1977)) bit minon u Well M adulm hw a

constitutionally protected right of privacy with respect to the use of contraceptives and that State restrictions on a minor’s privacy rights are valid only

if they serve any significant State interest. . . that is not present in the case of an adult. ” As of 1990, the U.S. Supreme Court had not directly addressed

the constitutionality of parental notification requirements that involve parents in decisions involving minors’ use of family planning sexvices.

1 ITF~eral Constlmtloml law qyding he ~~issible *OP of Smte re~tion of abofion is in flux. ~ the wake of its l~tik 1972 Roe V. Wade

decision (410 U.S. 113 (1973)), the U.S. Supreme Court issued several decisions that have extended (o minors at least some constitutional protections

with respect to abortion (e.g., any parental consent requirement for a minor’s abortion must be coupled with a ‘‘judicial bypass” procedure that allow

a minor to secure court approval for an abortion if she can meet certain requirements). Notable Supreme Court decisions dealing with parental consent

to a minor’s abortion include Planned Parenthood of Mhsouri v. Du#ort/t (428 U.S. 52 (1976)), III Bellotti v. Baird (13ellotti XI) (443 U.S. 622 (1979)),

City of Akron v. Akron Center for Reproductive Health, Inc. (462 U.S. 416 (1!373)), and Planned Parenthood Association v. Ashcrofi (462 U.S. 476

(1983)). A 1989 case that did not directly address the question of parental consent, Websrer v. Reproductive Health services (109 S. Ct. 3(MO (1989)),

appears to give States greater leeway in restricting abortions generally and has raised questions about whether past Supreme Court decisions dealing

with abortion will stand.

1 lgne U.S. Supreme COUrt has not ded[ extensively with parental notification in cases involving abortion WVices fOr minors. k June 1990, hwever.

the Court handed down two decisions that may furnish the impetus for further State legislative activity aimed at rqiring parental notification in the

case of a minor’s decision to have an abortioq Hodgson v. Minnesota (110 S. Ct. 2926 (1990)) and Akron Centerfor Reproductive Health (110 S. Ct.

2972 (1990)).
I-62. Adolescent Health-Volume I

●

●

I f

A little under half of States have statutes that

allow minors of a certain age to obtain outpatient mental health services without parental

consent. The majority of statutes are silent as to

parental notification, but the others have varying provisions.

Concern about the overuse of inpatient mental

health treatment for children119 is increasingly

encouraging States to move in the direction of

making it more difficult for parents to commit

their dependent children to inpatient psychiatric facilities (73a).120

Congress decides that greater coherence and

uniformity in State laws is desirable, it could enact

legislation conditioning States’ receipt of Federal

funds for specific purposes on the States’ having

statutes or administrative rules and regulations that

incorporate particular substantive policies with respect to health care decisionmaking by and for

adolescents. To OTA’s knowledge, this approach

has not been used by Congress in this realm to date.

What substantive requirements should be adopted

would depend on policymakers’ judgments regarding the appropriate balancing of the interests of the

state, adolescents, parents, and health care providers

(see discussion above). Different sets of rules may

appropriately govern the allocation of decisionmaking for adolescents of different ages and for different

types of services. In other words, the rules governing

the allocation of decisionmaking authority for young

adolescents may be different from those governing

the allocation of authority for older ones. Also, the

rules that govern the allocation of decisionmaking

authority for STD treatment, for family planning

services, for mental health services, for substance

abuse treatment and counseling, for abortion, and for

other services may all be different.

A Federal requirement conditioning States’ receipt of specified Federal funds on their allowing

adolescents who meet certain requirements to consent to treatment for STDs might not be particularly

onerous or controversial, because (as noted above)

most States already allow minors to consent to such

treatment as a public health measure. Fewer States

have statutes allowing minors to consent to other

types of services (contraceptives, outpatient mental

health services, drug/alcohol treatment services), so

the imposition of a Federal requirement giving

adolescents’ greater autonomy in these areas might

be more difficult. Any requirement having to do with

abortion is likely to engender considerable political

opposition.

Strategy 1-4: Congress Could Increase Support for

Training of Health Care Providers Who Work With

Adolescents

Many health care providers report, and objective

evidence also suggests, that health care providers

across disciplines (e.g., physicians, nurses, psychologists, social workers, nutritionists) are often unequipped to deal with issues that may be presented

by adolescents during a health care visit.121 Adolescents report that they are sometimes reluctant or

unwilling to consult with private physicians on

sensitive issues (e.g., those related to sexuality or

mental health problems), and the health issues of

concern to adolescents often differ from those

discussed by health care providers.122

To improve the quality of care and the approachability of care as perceived by adolescents, Congress

could increase support for a range of training

through a multiplicity of approaches, including:

● continuing education for health care providers

already in practice and interested in treating

adolescents;

. training in adolescent health issues for trainees

who are likely to see adolescents in their

practices; and

. specialized interdisciplinary training for those

who plan to work exclusively with adolescents.

Such a multiplicity of approaches would affect all

adolescents who come in contact with a health care

provider, although not immediately.

Issues-Several considerations may limit the

feasibility of increasing support for training of

! !9SW ~h. 11, ‘*Me~~ H~~ ~obl~s: ~ev~nti~n ad services, ” in Vo]. ~,

l~n Iw, (J&homa, Virgini% and Wyoming enacted such kws (Tsa).

l~l~s prob]em is discussed at length in ch. 15, “Major Issues Pertaining to the Delivery of Primary and Comprehensive Health Semices to

Adolescents, ’ in Vol. III.

IZzFor further discussio~ see ch. 6, “Chronic Physical illnesses: Prevention and Services, ” and ch. 11, “Mental Health Problems: Prevention and

Services, ‘‘ in Vol. II and ch. 15, ‘‘Major Issues Pert aining to the Delivery of Primary and Comprehensive Health Semiees to Adolescents, ” and ch. 17,

“Consent and Confidentiality in Adolescent Health Care Decisionrnaking, ” in Vol. III.
Summary and Policy Options . /-63

Photo credit: © Randall Hagadorn, Titusville, NJ

Specialized interdisciplinary training for health care

providers who work with adolescents is deemed

essential to providing comprehensive, coordinated

health services, but Federal support for interdisciplinary

training programs has declined since 1980.

health care providers who work with adolescents.

One is that support for such training would be costly.

Second, it is not clear that sufficient numbers of

health care professionals are available to be appropriate trainers. Third, specific criteria for training

programs have not been adequately evaluated in

terms of effectiveness in ameliorating adolescent

health problems or patient satisfaction. The second

problem will clearly take years to address fully, but

neglecting to move now will make the situation in

the future even worse. To deal with the third

problem, a rigorous evaluation component could be

a required condition of support for training, and the

Federal Government could help by providing technical assistance (e.g., on adolescent development and

health, on interpersonal styles relevant to adolescents) to training programs.

Strategy 1-5: Congress Could Take Steps

To Empower Adolescents To Gain Access

to Health Services

Information is generally scarce, but adolescents

seem largely disengaged from the health services

system. Adolescents, like most health care consumers, are rarely involved the design of services (225).

In addition to taking steps to increase the physical

availability, financial accessibility, legal accessibility, and approachability of the services themselves,

Congress could take steps to empower adolescents

in relation to the delivery of services. Empowerment

approaches take as a given that individuals, not just

professionals, have a set of competencies, that these

competencies are useful in the design and management of services, and, further, that those competencies can be even more fully developed by giving

individuals additional opportunities to control their

own lives (e.g., 173). Thus, in addition to empowerment’s benefits for individual adolescents’ sense of

competency, more proactive involvement of adolescents in the design of services would have the benefit

of making those services more responsive to the

more concrete health-related needs of adolescents.

Strategies for adolescent empowerment could involve two approaches: one is to support efforts to

educate adolescents about various aspects of using

health and related care services (Strategy 1-5a); the

second is to support the provision of opportunities

for adolescents to participate in decisionmaking

about the design and management of health services

(Strategy l-5b).

Strategy 1-5a: Encourage efforts to educate

adolescents, parents, health care providers, and

others who may identify adolescent health problems and make referrals, about the legal and

other aspects of using health services.

The provision of health care services in the United

States is complicated, and consumers must be

educated to use health services appropriately and

when they are needed. Systematic evidence is scant,

but available data suggest that, in many respects,

adolescents have insufficient information to be

active, engaged health care consumers. Striking

examples can be found in the report of the National

Adolescent Student Health Survey (10). With respect to knowledge about when to seek health care

services for STDs, for example, 33 percent of

students surveyed (8th and l0th graders) did not

know that a sore on the sex organ is a common early

sign of an STD; 44 percent did not know that a

discharge of pus from the sex organ is a common

early sign of an STD; 41 percent did not know that

experiencing pain when going to the bathroom is a

common early sign of an STD; and 43 percent did

not know that it is harmful to wait to see if the signs

of STDs go away on their own (10). With respect to

how to gain access to treatment for STDs, 76 percent

of the adolescents surveyed were either unsure or

mistakenly believed that the Public Health Department must inform parents about STDs in patients

under age 18; 79 percent were either unsure or

mistakenly believed that most clinics must have

parental permission to treat patients under age 18 for

STDs; and 39 percent reported that they would not

know where to go for medical care if they thought
1-64. Adolescent Heatlh-Volume I

they had an STD (10). With respect to suicide

prevention, approximately one-third of students

surveyed did not recognize common signs of possible suicide, and 65 percent of adolescents surveyed

could not or did not know whether they could locate

a community agency for suicide prevention (10). As

noted above (Strategy 1-3 on improving adolescents’ legal access to services), laws pertaining to

adolescent consent and confidentiality are inconsistent not only across States, but across problem and

service areas within States; thus, it is not surprising

that adolescents may be ill-informed about access to

health services.

Issues—Knowledge about the availability and

need for health services imparted independently to

adolescents could be perceived (as health education

often is) as interfering with parental prerogatives.

But in fact, if done well, it could open up avenues for

parent-child discussion, and opportunities for parents to help educate their children about using health

care services, Adolescents who objected to certain

restrictions, rights, or lack of services, might be

stimulated to become involved in the political

system. Consideration would have to be given to

delivering the information in a developmentally

appropriate manner, based on the adolescent’s actual

needs. Currently, the appropriateness of information

to developmental and experiential status is recognized as an important aspect of health education, but

approaches to developing and imparting information

appropriately have not been wholly crystallized

(29,153,279). More participatory approaches to

health education for adolescents should help (see

Major Option 2, Strategy 2-2b on supporting innovative health education research and demonstration

projects, below), as should greater training in

adolescent development and health issues for health

educators and other health care providers (see Major

Option 1, Strategy 1-4 on increasing support for such

training, above).

Photo credit: Kaiser Teen and Young Adult Health Center,

Granada Hills, CA

Adolescent participation in health services planning can

take the form of special adolescent advisory panels or

adolescent representatives on general advisory boards.

The Kaiser Permanence health maintenance organization

in Granada Hills, California, asks adolescents to provide

advice on a regular basis.

Strategy l-5b: Provide incentives for or mandate adolescent participation in the design of

programs and research that affect adolescents at

the Federal, State, local, and private level.

Adolescent participation can take the form of

special adolescent advisory panels such as the Youth

Advisory Panel that assisted in the preparation of

this OTA Report (see app. A, “Method of the

Study’ or of adolescent representatives on general

advisory boards.123 Several organizations have been

experimenting with adolescent participation (e.g.,

the Center for Population Options, the Child Welfare

League, the Kaiser Permanence health maintenance

organization in the Los Angeles area) and should be

able to provide advice to organizations interested in

involving adolescents in governance. 124

Issues-Taking adolescents’ views into account

is a difficult process that may be unfamiliar to many

professional organizations. Not only will the usual

conflicts between citizens and professionals be at

Izssome elemats of tie exmutive branch me showing interest in the concept of empowerment as a strategy for helping to improve individuals’ life

situations (55). Explicit government support for citizen participation in human services progmrns was more prevalent in the 1970s. For example, the

Community Mental Health Centers Amendments of 1975 (Public Law 94-63) included requirements for citizen participation in govesnan ce and in

program evaluation but the requirement for citizen evaluation was overturned with the enactment of aleoho~ drug abuse, and mental health block grant

legislation (Public Law 97-35) (268,269). Tbe National Institute of Mental Health reported in 1984, however, that citizen evaluation in mental health

services seemed to be “well-established” (269). Existing requirements for citizen participation in research services, and program evaluation include

the national adviso~ boards of various Public Health Service and National Institutes of Health agencies (research), and the Working Group for

Community Development Reform (monitoring and evaluation of community development block grants), f~ced through a Title IX grant from the

Community Services A&rum- “stration in DHHS.

t24~e YOW ~en- &t ~bfic ~w 101-501)” (diwus~ &IOw) rq~stie p~cipation of yo~ people in the Federal Council on chil~

Yout.tL and Families md the 1993 White House Conference on Childreq Yout.tL and Families established by the act.
Summary and Policy Options ● 1-65

issue (269), but professionals and adolescents are

particularly likely to have different styles of communication and understandings of system limitations.

Adolescent involvement can be expected to be

time-consuming and may require additional sensitivity training for professionals and adolescents.

Thus, if such participation is mandated or encouraged, it should be accompanied by appropriate

supports.

Major Option 2: Congress Could Take Steps To

Restructure and Invigorate the Federal

Government’s Efforts To Improve

Adolescents’ Health

As noted earlier, OTA found that Federal efforts

in the area of adolescent health are undertaken by a

broad range of U.S. executive branch agencies and

congressional committees (see tables 2 and 3 in

“Major Findings”). Generally speaking, Federal

efforts tend to be condition-specific rather than

population-specific. A major consequence is that

adolescent health initiatives by the Federal Government are often seriously fragmented and inappropriately focused. Many important adolescent health

issues lack visibility and attention.

Five general strategies Congress could follow to

restructure and invigorate the Federal Government

efforts to improve U.S. adolescents’ health are

shown in table 6. To address the issues of fragmentaion, inappropriate focus, and lack of visibility for

adolescent health issues, Congress could create the

locus for a strong Federal role in addressing adolescent health issues (Strategy 2-1). Other strategies

would be to encourage the U.S. executive branch to

invigorate traditional Federal activities in program

development (Strategy 2-2), basic research (Strategy

2-3), and data collection (Strategy 2-4). The most

ambitious approach would be to combine all four of

these approaches (Strategy 2-5).

Strategy 2-1: Congress Could Create a Locus for a

Strong Federal Role in Addressing Adolescent

Health Issues

Even if Congress acted on many of the suggestions in this Report, specific incremental improvements in and of themselves are unlikely to have very

much impact without some central locus from which

adolescent health efforts can be monitored and either

directed or coordinated. Currently, at least seven

Cabinet-level departments in the U.S. executive

branch (Health and Human Services, Education,

Defense, Labor, Transportation, Justice, and Agriculture) and two independent agencies (ACTION

and the Consumer Product Safety Commission)

have a major role in addressing adolescent health

and related issues (see table 2 and figure 13 in

“Major Findings”). Numerous agencies within

DHHS (and to a lesser extent, the other departments)

are involved in adolescent health issues. But no

single Federal agency has the mandate or resources

to oversee the many diverse issues and programs

related to adolescent health. In 1990, the 10lst

Congress enacted the Young Americans Act as part

of the reauthorization of the Head Start program

(Public Law 101-501), Modeled after the “Older

Americans Act,” the legislation aims to create a

coordinated Federal response to the multiple needs

of children.125 Although many of the program areas

mentioned in the legislation are specific to adolescents (e.g., teen parenting support, teen pregnancy

prevention), and others are relevant to adolescents

(e.g., housing and shelter assistance, education and

training services, protective services, recreational

and volunteer opportunities, community referral

services, outreach services), it is still too early to tell

how much adolescent issues will be emphasized in

the implementation of the legislation.

OTA finds that a number of functions that are

related to improving adolescent health are not being

adequately performed. These functions (listed below)

lzs~e new law establishes sever~ Federal initiatives to promote ‘‘the best possible physical and mental health’ for w children ~d you~ ~clud~:

an office of ‘Commissioner’ within the Administration on Childrem YoutlL and Families of DHHS, to sefve as an advoute for chfldren aCrOSS

Federal agencies;

a State grant program to assist States with the planning and coordination of services and developing family resource and support programs;

a National Center on Family Resource and Support programs to gather and disseminate information and provide training on family resources and

support programs;

a Federal Council on Children, Youth, and Families to evaluate Federal policies and programs affecting young people and advise the President on

such issues; and

a 1993 White House Conference on Children, Youth, and Families to examine issues affecting children and youth and make recommendations for

further action.
Table 6-Strategies for Major Option 2: Congress Could Take Steps To Restructure and Invigorate the Federal Government’s

Efforts To Improve Adolescents’ Health

lime for Rough estimate of (direct)

Strategy Policy issue addressed expected impact cost to Federal Government

Strategy 2-1: Congress could create a locus for a strong Federal role in

addressing adolescent health Issues.

2-1 a: Create a new Federal agency at the Cabinet level, with line

responsibilities, to undertake broad efforts related to improving

adolescents’ health.

2-1 b: Create a new Federal agency at the Cabinet level, but without

line responsibilities, to coordinate efforts related to adolescent

health.

2-1 c: Create a new agency within an existing Cabinet department

(e.g., U.S. Department of Health and Human Services) to

address adolescent health issues.

2-1 d: Mandate the creation of a strong interdepartmental, interagency adolescent health coordinating body,

Strategy 2-2: Congress could encourage the U.S. executive branch to

invigorate traditional Federal activities in program development.

2-2a: Encourage the U.S. executive branch to support program

development or demonstration projects in specific neglected or

promising areas related to the prevention and treatment of

adolescemt health problems.a

2-2b: Provide support for multisite rigorous research and demonstraion projects that test and compare suggested new comprehensive and innovative models of education for health.

Strategy 2-3: Congress could encourage the U.S. executive branch to

invigorate traditional Federal activities in research on adolescent

development.

2-3a: Require the U.S. executive branch to establish a permanent

council or counils to provide ongoing advice to Federal

agencies on research directions in adolescent health.

2-3b: Support, or encourage the U.S. executive branch to support, a

symposium or symposia on adolescent research issues.

Strategy 2-4: Congress could encourage the U.S. executive branch to

invigorate traditional Federal activities in data collection.

2-4a: Require the appropriate U.S. executive branch agency to

provide Congress with periodic (e.g., every 2 years) reports on

the health status of U.S. adolescents and require that these

reports be made available to the public.c

2-4b: Support and encourage local efforts to collect adolescent

health information that will be, at least in part, able to be

compared to national evel data.

Strategy 2-5: Congress could create a locus for a strong Federal role In

addressing adolescent health Issues and invigorate traditional

Federal activities in program development, research, and data

collection.

Highest coordination, highest

visibility for adolescent issues

Some coordination, high visibility for adolescent issues

Coordination, visibilit y for

adolescent issues

Coordination

Provide needed services, enhance future policy decisions

Provide needed information to

adolescents, enhance future policy decisions

Coordination, raise level of research, attention to important

issues, innovation

Coordination, raise level of research, attention to important

issues, innovation

Coordination, visibility, U.S. executive branch accountability,

resource planning

Resource allocation

Depends on specific strategies

selected

immediate

Long term

Medium term

Long term

Immediate and long term

immediate and long term

Short to medium term and

long term

Longer term

Immediate and long term

Longer term

Depends on specific strategies selected

High

Medium

Medium

Low

Depends on number and

type of activities supported

Medium

Lowb

Lowb

High

Could be high

Depends on specific strategies selected

aS@f~ ar~ f~nd by OTA to be h particular need of development are Iiated in takde 7.

b~s not ind@ the cost of funding actual research.

%ongress could frame the request in such a way that spedfic health-related findings for specific age, gender, racial, ethnic, income, regional, and residential groups are highlighted. This would

encourage the collection of appropriate data.

SOURCE: Office of Tbnology Aaaeaament, 1991.
Summary and Policy Options .1-67

could be undertaken by a new adolescent health

agency or coordinating body:

●

●

●

•

●

●

●

●

●

monitoring of trends in adolescent health;

coordination of research;

overseeing the design of, support for, and

evaluations of, adolescent health services;

overseeing and coordinating training for service providers who work with adolescents;

providing a focal point for adolescent participation in policymaking;

providing a focal point for a national advisory

body on adolescent issues;

coordinating the diverse activities of Federal

agencies as they relate to adolescents;

interpreting and overseeing congressional mandates; and

advising Congress on adolescent health issues.126 

Congress could take any of several approaches to

the creation of a locus for a strong Federal role in

addressing adolescent health issues: create a new

Federal agency at the Cabinet level with line

responsibilities (Strategy 2-la) or without line

responsibilities (Strategy 2-lb) or create a new

Federal agency within an existing Cabinet department (Strategy 2-1c) or create a new interdepartmental, interagency adolescent health coordinating body

(Strategy 2-id) (see table 6).

With the adoption of any of these strategies, two

issues will remain. One is how to design Federal

policy so that it would be refocused to reflect a new

approach that reflects the guiding principles of

attention to adolescent environments (in addition to

their behaviors and disorders) within a prolonged

sympathetic and supportive context. The mere

existence of a new agency or coordinating body,

even though such a body would raise the visibility of

adolescent health issues, would not be enough to

accomplish this goal; congressional oversight could

ensure that this approach is followed. The recently

enacted Young Americans Act takes an exemplary

approach because it is aimed at improving social

environments for young people and their families by

emphasizing the creation of programs that: support

families, create community referral services, and

provide high-quality educational opportunities (Public Law 101-501, Title IX, Chapter 2, Sec. 932).

The second issue is to which congressional

committee(s) a new adolescent health agency or

coordinating body would report in the Congress.

currently, multiple congressional committees have

interests in and jurisdiction over specific adolescent

issues (see table 3 in “Major Findings”). The

variety of congressional mandates is one reason

cited by executive branch agency representatives for

the current lack of coordination on adolescent health

issues in the executive branch.

Strategy 2-la: Create a new Federal agency at

the Cabinet level, with line responsibilities, to

undertake broad efforts related to improving

adolescent health.

The advantages of having a new Cabinet-level

agency with line responsibilities is that such an

agency would be highly visible, would have the

authority to perform many of the functions that are

widely regarded as needed (see above), and, importantly, would cross current departmental lines. On

the other hand, creating a separate department solely

for adolescent health and related issues might create

an unwanted precedent. Further, it could not fully

resolve redundancies and gaps across topics (e.g.,

highway safety, disabilities, vocational training) or

age groups.

Strategy 2-lb: Create a new Federal agency at

the Cabinet level, but without line responsibilities, to coordinate efforts related to adolescent

health.

A separate office on a level with other Cabinet

departments but without line responsibilities (analogous to the Office of National Drug Control Policy)

would provide more visibility and coordination

across department lines than would a new agency

within a single department. However, policies drawn

up in such an office might not be accepted by other

departments.

Strategy 2-lc: Create a new agency within an

existing Cabinet department (e.g., the U.S. Delz~R~ently, the Fede~ Govemrnenthas been recognizing thecross-condition needs of other population groups. primary examples include tie Nation~

Institute on Aging (within the Nauonal Institutes of Health of DHHS), the Qt%ce of Minority Health (in the Public Health Service of DHHS), and the

Office of Women’s Health Research (within the National Institutes of Health). These efforts are small, generally research- rather than semice-focused,

and at least one (by the DHHS Office of Minority Health) was criticized for its lack of initiative (211). Subsequently, Congress authorized separate

funding for the Office of Minority Health (Public Law 101-527), Nevertheless, these efforts do represent a recognition that disease-focused activities

may not be sufficient to seine the needs of certain groups,
I-68 ● Adolescent Health-Volume I

partment of Health and Human Services) to

address adolescent health issues.

DHHS currently has the broadest mandate and

level of expenditures related to adolescent health

issues (see table 2 and figure 13 in “Major Findings’ ‘). Thus, DHHS seems a likely place within

which to create a new agency with broader responsibility for adolescent health issues. Such an agency

could perform many of the functions suggested

above. A new agency within DHHS could be

situated high enough within the Department to

ensure comparability of standing with other DHHS

agencies with current major, but disparate, roles in

adolescent health issues. Budgets and responsibilities from existing DHHS agencies with major roles

in adolescent health issues could be transferred to

the new agency. Even so, cooperative efforts within

DHHS would still be required because many health

and health care issues affecting adolescents require

strategies that are disease-specific or that cross

population groups (e.g., families, children of all

ages, older adolescents and young adults, racial and

ethnic minorities, rural people). In addition, strong

mandates for collaboration among such a DHHS

agency and both independent agencies and agencies

in other departments, or possibly the moving of

certain of the other agencies’ functions (e.g., those of

the Office of Juvenile Justice and Delinquency

Prevention in the U.S. Department of Justice) to

DHHS, could help to ensure a more consistently

coordinated adolescent effort.

Strategy 2-id: Mandate the creation of a

strong interdepartmental, interagency adolescent health coordinating body.

Mandating the creation of an interdepartmental,

interagency adolescent health coordinating body

seems the weakest strategy of the four for strengthening the Federal role in adolescent health. A

coordinating body similar to some of those that

Photo credit: Office of Technology Assessment

Programs to distribute bicycle helmets or other protective

equipment to adolescents in economic need are an

example of a potentially effective accidental injury

prevention strategy.

already exist would have little visibility and no

accountability. 127 If the creation of a new adolescent

health agency, even within an existing department,

is thought to be unworkable, however, Congress and

the executive branch might be able to structure the

creation and implementation of a coordinating body

so that the coordinating body is visible, accountable,

and potentially effective in strengthening the Federal role in adolescent health and related issues.

Even without mandating or encouraging the

executive branch to restructure Federal efforts in

improving adolescent health, Congress could act to

invigorate traditional Federal efforts in program

development (see table 6).

127FOr ~xmple, ~ ~genCy on ad~l~~n[ re~~ch issues w~ cr~t~ ~ 1972 ~ ~ offsh~t of the ~t~g~rq Pmel on Edy Childhwd Re-h

and Development itself established in 1970 in response to evidence that agencies sometimes “duplicated researeh and ignored important gaps in

research’ (258). hording to a recent document by the Panel, now known as the Interagency Panel on Research and Developmert4 “For many years

the two panels were supported by a central contractor who developed and ran an information system that tracked salient information on each research

project funded by member agencies. In additio~ special studies were performed on cross-cutting issues that were common to the work performed by

the agencies on selected topics of speciat interest to member agencies as weIl as reviews of currently funded research. ’ However, the information system

and research activities were eventually discontinued. In 1985, the two panels were combined into a single interagency panel on research and development

on children and adolescents. Now, the panel’s work consists largely of monthly meetings in which information on member activities is presented and

suggestions for joint research may be made, and an annual conference in which special topics are addressed in depth. Panel members include

representatives of ACTION, and the U.S. Departments of Agriculture, Defense, I?ducatiou Health and Human Services, Justice, bbor, State, and

Transportation. The panel is chaired by a representative from the Administration on Children, Yout4 and Families in the Family Support Administration

of DHHS. Other examples of existing and past coordinating bodies with a role in adolescent health can be found inch. 19, ‘‘The Role of Federal Agencies

in Adolescent Health’ in Vol. Ill.
Summary and Policy Options . /-69

Photo credit: Benjamin Smith, Washington, DC

There is Iittle systematic information about effective means

of preventing adolescent involvement in violence.

Congress could support demonstration projects

based on promising models.

Strategy 2-2: Congress Could Encourage the

Executive Branch To Invigorate Traditional Federal

Activities in Program Development

One of the traditional missions of the Federal

Government is to provide leadership in the development of new and innovative programs to improve the

health of the population. To invigorate Federal

activities in program development related to adolescent health, Congress could encourage the executive

branch to support program development or demonstration projects in specific neglected areas of

prevention and treatment (Strategy 2-2a). A second

approach would be to support demonstration projects that use a comprehensive integrated approach to

Photo credit: Benjamin Smith, Washington, DC

Very often, adolescents have Iittle control over the food

available to them. Congress could support efforts to

provide better nutritional choices to adolescents.

health education within the framework of health

promotion (Strategy 2-2b). This approach would cut

across many specific areas in adolescent health

promotion and problem prevention (and, to some

extent, treatment).

Strategy 2-2a: Encourage the executive branch

to support program development or demonstration projects in specific neglected areas related to

the prevention and treatment of adolescent

health problems.

In addition to facing special barriers in access to

health services, many adolescents have or are at risk

for one or more specific critical health problems.

The level of conclusive evidence for “what works”

in terms of health promotion, disease prevention,

and treatment varies by problem, In some areas (e.g.,

provision of contraceptive services, mental health

services, life-skills training), existing evidence often

provides strong indicators of the kinds of promising

interventions that deserve additional testing and

evaluation. In other areas (e.g., child welfare,

hopelessness prevention), a considerable amount of

additional analysis may be required to determine the

kinds of specific approaches that may be effective

for prevention and treatment.

Table 7 displays examples of selected programs or

approaches that OTAs analysis suggested were

either: 1) innovative and promising (e.g., life-skills

training for adolescents at risk of alcohol, tobacco,

and drug abuse) or 2) in areas that were in serious

need of innovative program development and evalu-
I-70. Adolescent Health—Volume I —

Table 7—Promising or Neglected Areas of Adolescent Health Promotion, Problem Prevention, and Treatment:

Examples of Program Development Needsa b

Promising or neglected areas of adolescent health promotion and problem prevention: examples of areas in particular need of

program development and accompanying evaluation

● To improve family environments:

—innovative methods for dissemination to parents of accurate and useful information about adolescent development and appropriate

parenting

—interventions to help prevent problems in adolescents from single-parent or stepparent families

● To improve school environments:

—Peer tutoring

—Decentralized decision making

—innovative approaches to parental involvement

● To improve adolescents’ use of discretionary time:

—Recreational facilities and programs (e.g., pools, gymnasiums, parks)

---Community service programs

● To reduce accidental injuries:

—innovative methods for school-based driver education

—Programs to distribute free protective equipment (e.g., football and bicycle helmets) to adolescents in economic need

. To improve nutrition and fitness:

—innovative attempts to provide food widely regarded as healthfui

—Education of physical education teachers, coaches, trainers, etc., about adolescent-specific factors that could influence adolescents’

physical abilities

--Nutrition education

● To improve dental and oral health:

—Preventive education on dental and oral hygiene and health, including information about obtaining access to needed services, when

needed (e.g., for low-income adolescents)

. To prevent AIDS and other sexually transmitted diseases:

--Condom distribution accompanied by education about the prevention and treatment of human immunodeficiency virus (HIV) and

sexually transmitted diseases

—Education on access to clinical preventive and treatment services

● To prevent adolescent pregnancy:

-Contraceptive distribution accompanied by family life education for adolescents particularly likely to be sexually active (e.g., eider

adolescents)

-Sexuality/pregnancy prevention education for young adolescents, before they are likely to be sexually active

—Parent-child communication groups with a focus on sexuality

—Broad-based, intensive programs emphasizing life-options discussions and experience plus discussions of sexuality

. To promote mental health and prevent mental health problems:

--Social competency-based mental health promotion efforts

. To prevent alcohol, tobacco, and drug abuse:

—Additional support for life-skills training

● To prevent delinquency:

-Comprehensive, intensive efforts early in life (e.g., Perry Preschool Program, parent-skill training) and after problems have appeared

(e.g., intensive psychotherapeutic and vocational-education intervention)

--Supervised integration of identified antisocial adolescents into activities with nondisturbed peers

—Violence prevention curricula

—Victimization prevention curricula

. To prevent homelessness:

—Prevention of abuse in families; treatment services for abusive families

—Education for families of homosexual adolescents

Adolescent treatment service delivery: examples of areas in particular need of program development and accompanying

evacuation

. To improve family environments:

—innovative approaches to child welfare services for adolescents

—Family counseling/therapy, especially for abusive or dysfunctional families

. To improve services for chronic physical illnesses:

—Efforts to reduce fragmentation in delivery of health services to adolescents with serious chronic physical illnesses

—Efforts to inform adolescents about the availability of treatments for problems of importance to them (e.g., acne, dysmenorrhea)

. To improve nutrition and fitness:

-See “to improve use of adolescents’ discretionary time” above regarding providing fitness opportunities

● To treat AIDS and other sexually transmitted diseases:

—innovative, sensitive, and flexible approaches to treatment for STDs

-Outreach efforts to bring adolescents into AIDS clinical trials

. To prevent adverse effects of pregnancy and parenting for adolescentsd:

-Outreach and intensive comprehensive services (e.g., housing, child care, transportation) to keep pregnant and parenting

adolescents in school
Summary and Policy Options .1-71

Table 7—Promising or Neglected Areas of Adolescent Health Promotion, Problem Prevention, and Treatment:

Examples of Program Development Needsab-Continued

● To treat mental health problems:

—Information to adolescents about when and how to seek mental health services

-Systematic comparisons of processes and outcomes for inpatient v. outpatient treatment

—Innovative approaches to case management and financing (e.g., “wraparound” funding)

—Innovative mental health treatment approaches, such as home-based and therapeutic foster care, compared to traditional

approaches (outpatient therapy, inpatient treatment)

. To treat alcohol, tobacco, and drug abuse:

—Innovations in access to early intervention (e.g., student assistance programs, school-linked health centers)

—Information to adolescents about when and how to seek treatment services

• To treat delinquent adolescents:

—Innovations in the delivery of health services to adolescents in juvenile justice facilities

-Systematic comparisons of outcomes for a broad range of more and less punitive approaches (e.g., private v. public facilities;

community-based v. facilities away from the adolescents’ home community; open v. dosed facilities; “boot camps” v. traditional

approaches)

● To provide services to homeless adolescents:

comprehensive (e.g., for physical health, mental health, substance use), intensive services for homeless adolescents

—Transitional living

aFor a~l==nt~, as di~cu~se~ “n&r 1(M~or findings,” the areas of health promotion, problem prevention, and treatment Often OVedap.

%otethat this is not a comprehensive list of adolescent health problems and solutions, but a list that includes: service systems in dire need of innovative and

rigorously evaluated approaches (e.g,, the child welfare system); specific interventions that are being widely used but have not been adequately evaluated

(e.g., inpatient v. outpatient treatment for mental health problems); interventions that appear promising but have not been widely tested (e.g., violence

prevention curricula; distribution of free or low-cost bicycle helmets, paired with an educational campaign); and types of interventions that appear promising

but have not been tested with adolescents to OTA’s knowledge (e.g., victimization prevention). This list arguably does not include the most imprtant

approaches, which are: 1 ) to develop methods of comprehensively addressing adolesmnt health issues, wfthin a cmntext of health promotion, rather than

splintered efforts to prevent discrete problems, 2) to increase adolescents’ access to health services through changes in health financing, and 3) to improve

adolescent environments through interventions that are already known to be effective (e.g., fluoridated water).

%Iinical preventive services are services that prevent the occurrence (e.g., through contraception) or potential worsening (e.g., through screening for

conditions) of clinical conditions.

*his Report focused on the prevention of adverse effects of pregnancy for adolescents, although, as discussed in the chapter on families, healthy mothers

and fathers are essential to healthy infants and children, An earlier OTA report, /+aMryChi/&en. /nvestingin fhe Fufure, focused on preventive health services

in the prenatal and early infant period to protect the health of young infants and children (224).

SOURCE: Office of Technology Assessment, 1991.

ation (e.g., child welfare, health care in the juvenile

justice system). The examples are listed by goal

(e.g., ‘‘to improve family environments’ ‘).

Issues—In designing and funding programs and

demonstration projects on specific issues and service

delivery systems, it would be important for executive branch agencies to be mindful of several factors:

critical definitional issues regarding adolescent

health concerns (box A in “Introduction”); the

apparent, but inconstant, interrelatedness of some

adolescent health problems (165); the fact that

interventions can have multiple intended outcomes;

the low base rate of some high-visibility problems;

and the ‘‘partially inconsistent assumptions about

evaluation’ made by the variety of disciplines

involved in adolescent health intervention (41). One

approach to these issues is adequately to conceptualize and measure the problem, the intervention, and

the possible outcomes.

Strategy 2-2b: Provide support for multisite

rigorous research and demonstration projects

that test and compare suggested new comprehensive and innovative models of education for

health such as those suggested recently by the

Carnegie Council on Adolescent Development,

the National Commission on the Role of the

School and the Community in Improving Adolescent Health, and the Centers for Disease Control.

Another approach to program development in

health promotion and problem prevention is to take

a more broad-based approach to school-based educational approaches to adolescent health. In the

United States, there is little in-depth understanding

about the way health education is delivered to

adolescents, In but concerns have eventuated in a

consensus that changes in the delivery of health

education are needed. In recognition that most

contemporary health education efforts are neither

appropriate for adolescents nor effective, a task force

of the Carnegie Council on Adolescent Development, the National Commission, and the Centers for

Disease Control have recently generated suggestions for change (29,153,279). Their recommenda128see, for example, Ch. 10, “Pregnancy and Parenting: Prevention and Services, ” in Vol. II.
I-72 ● Adolescent Health--Volume I

tions regarding school-based health education are

presented in box C in “Major Findings. ”

Common themes in these groups’ recent recommendations include the need for health-related

education to begin early, be developmentally appropriate, involve life-skills training, involve the active

participation of adolescents, and be part of a general

approach to health that includes improved access to

health services (29,153,279). Some have felt the

need to recommend explicitly that information be

honest and relevant (153). Others suggest that health

education be part of an integrated life-sciences

curriculum and, more importantly, that health education be integrated into overall school environments

that are health-promoting (29). OTA’s analysis

suggests another consideration: that education for

health include information about gainin g access to

health services, even if such services are not

school-linked. And OTA’s Adolescent Health Youth

Advisory Panel expressed an interest in health

education that was immediately relevant to what

they view as one important aspect of their lives:

interpersonal relations (235). The Youth Advisory

Panel’s concern is consistent with societal interest in

reducing adolescent pregnancy, interpersonal violence, and, potentially, the high divorce rate among

adults (292,293). 129 While these recommendations

seem eminently logical, there is still some inconsistency among them, and none of them have been

tested systematically.

Issues—It is important to note that existing

recommendations on health education are limited to

school-based health education. There are no attempts known to OTA to conceptualize a method of

providing comprehensive health education for adolescents who are not in school.130

A second issue is that school-based prevention

efforts could continue to tend to be didactic and

relatively passive rather than proactive. Proactive

efforts are those that attempt to promote health and

prevent the occurrence of problems by changing

environments rather than merely attempting to

change individual behavior.131 By integrating health

education efforts into the school and community

environments (including, if available, comprehensive health and related services), the danger of

limiting health education to “lectures” on the “four

food groups” (151) can be avoided. Were health

education to be well-integrated into a total school

and community environment, however, evaluation

of the effectiveness of any particular component is

made more difficult.

A fourth issue in attempting to provide quality

health education in the schools is the frequent

political divisiveness encountered when the discussion of morally difficult issues with minors is

proposed.

Further conceptualization and testing of multiple

components of an integrated approach is clearly

needed, but an often effective approach to implementing improvements is to make theoretically

reasonable changes and carefully observe the effects

of those changes (1 17).

Strategy 2-3: Congress Could Encourage the

Executive Branch To Invigorate Traditional Federal

Activities in Research on Adolescent Development

This Report and other recent documents specifically focused on either adolescent development and

health (62,95,340) or on the Federal role in financing

research on the topic of adolescent development and

health (144) are unanimous in concluding that

Federal efforts in research related to adolescent

development and health have been and continue to

be dismally inadequate and shortsighted.

As mentioned previously, overall Federal research expenditures on adolescent development and

health are small, focused on a relatively narrow

spectrum of problems, and freed on an even narrower set of solutions. Although the problems

typically emphasized may be costly and important,

with potentially disastrous implications for adolescents’ futures (e.g., serious delinquency, unprotected pregnancy and parenthood), there is little

indication in current Federal policy and programs of

concern for the context and entirety of adolescents’

lz~e 1988 DHHS Natio~ Swvey of Family Growth found that more than OWAhh’d Of fht marriages among women ages 15 to 44had already ended

in separation divorce, or widowhood, and among women who had been married for the fmt time in 1974 or earlier, the proportion of disrupted fmt

marriages approached half (293). Also see ch. 3, “Parents’ and Families’ Influence on Adolescent Healti ” in Vol. H.

l-e Centers for Disease Control in DHHS is charged with developing h~ immunodeficiency virus (HIV)-related education prevention for

out-of-school youth. For discussion see ch. 9, ‘‘AIDS and Other Sexually Transmitted Diseases: Prevention and Services, ” in Vol. II.

lslse]~ted ~jor strate~es for improving adolewents’ environments are discussed below under Major Option 3 (“congress co~d tie StepS to

improve environments for adolescents’ ‘).
Summary and Policy Options .1-73

lives, a situation that has left informed observers

perennially disappointed with the Federal role in

improving adolescents’ lives and health.

Congress could help to substantially revitalize the

research agenda related to adolescent development

and health. Research on adolescent health and

development issues should be approached in a

consistent, comprehensive, coordinated, sensitive,

and supportive manner. To oversee the development

of a research agenda, Congress could require that the

executive branch establish a permanent council or

councils to provide ongoing advice to Federal

agencies on research directions in adolescent health

(Strategy 2-3a). Alternatively, or in addition, Congress could support a symposium or symposia on

adolescent research issues (Strategy 2-3b).

Strategy 2-3a: Require the executive branch to

establish a permanent council or councils to

provide ongoing advice to Federal agencies on

research directions in adolescent health.132

A permanent council or councils would provide

executive branch agencies the benefit of advice on

adolescent health and development issues from

leading practitioners in the field. This strategy is a

relatively low-cost way to potentially raise the level

of federally funded adolescent development and

health research and would probably have beneficial

repercussions for non-federally funded research.

One hazard to avoid in establishing a Federal

advisory board or boards is domination by a single

professional discipline. In addition, strong adolescent participation in the symposia or advisory

councils and explicit attention to reconceptualizations of adolescent health issues (e.g., in a symposium designed for that purpose) would help to

ameliorate any tendencies to remain in the traditional frameworks.

Alternatively, or in addition to the permanent

advisory council or councils:

Strategy 2-3b: Support, or encourage the executive branch to support, a symposium or symposia on adolescent research issues.

Such symposia could address the development of

research agendas in normal adolescent development,

risk and protective factors in adolescent health and

Photo credit: Benjamin Smith, Washington, DC

Congress could encourage the U.S. executive branch to

strengthen traditional Federal activities in research on

adolescent development and health. One strategy would

be to require the establishment of a permanent advisory

council or councils to advise Federal agencies on research

directions; another would be to support a symposium or

symposia on adolescent research issues. Advice from a

range of disciplines and from adolescents would be helpful.

well-being, health promotion and disease prevention, treatment services, and nontraditional strategies for improving adolescent health and well-being.

They could help to energize the research community

and stimulate cross-fertilization of ideas.

Analyses in OTA’s Report, and in other recent

volumes on adolescent development, health, and

health services (8,5 1,62,93,102,153,340), can help

to provide the groundwork for an improved approach to adolescent health research.

132TMS council orcounci]5 could be sitiarto those currentty advising the National CancerInstitute (within the National institutes of H~ti of D~S)

and the National Institute of Mental Htnlth (within the Alcohol, Drug Abuse, and Mental Health Adrninistmtion of DHHS).
I-74 ● Adolescent Health--Volume /

If implemented in addition to a permanent advisory council or councils, these symposia could be

guided by, and work in tandem with, the advisory

council(s). Adolescent participation could be encouraged in the symposia as well as in the advisory

boards.

Strategy 2-4: Congress Could Encourage the U.S.

Executive Branch To Invigorate Traditional Federal

Activities in Data Collection

National and local information on adolescent

health, health problems, and health services is

typically unavailable or deficient. 133 Data for monitoring adolescent health status, health and related

services utilization, and barriers to access are

currently insufficient in terms of topics covered,

ages reported on, and ability to disaggregate data for

specific racial, ethnic, income, gender, age, regional,

and residential groups.

To encourage the collection and dissemination of

data on adolescent health, Congress could require

periodic reports to Congress on the health status of

U.S. adolescents (Strategy 24a) and support local

efforts to collect adolescent health information

comparable to national level data (Strategy 2-4b).

Strategy 2-4a: Require the appropriate U.S.

executive branch agency 134 to provide Congress

with periodic (e.g., every 2 years) reports on the

health status of U.S. adolescents and require that

these reports be made available to the public.

The reports should include information on the

following:

●

●

a comprehensive range of health status measures (e. g., self-reported risk and protective

behaviors, self-perceived emotional status, selfperceived physical health problems);

utilization of the range of health services

providers and settings likely to be seen by

adolescents (e.g., guidance counselors, school

nurses, teachers (for counseling and guidance),

coaches, mentors, adolescent and adult friends,

psychologists, nurses outside the school, social

workers, nutritionists, and physicians, in

schools, urgent/emergency care centers, hospitals, youth serving agencies, sports facilities,

workplaces, and private offices);

Photo credit: Mark Charette, Washington, DC

Congress could require the appropriate U.S. executive

branch agency to provide Congress with periodic reports

on a comprehensive range of adolescent health status and

health and related services indicators. Such a requirement

would promote the collection of appropriate information.

. availability and utilization of recreational facilities and outlets;

● volunteer and paid work activities; and

● other environmental risk and protective factors

(e.g., family structure, abuse, neglect).

Congress could frame the request in such a way that

health-related findings for specific age, gender,

racial, ethnic, income, regional, and residential

groups are highlighted. This would force the eventual collection of appropriate data.

Issues-Clearly, the U.S. executive branch is not

currently equipped to regularly provide Congress

with adolescent related-reports of this broad nature

(260; see app. C). Requiring such reports, however,

would compel the executive branch to begin compiling such data as are available and to determine the

kinds of data not currently available.

A second issue is that national data, while useful

in suggesting broad trends in adolescent health and

access to health and health services, are certainly not

sufficient guides for use in local practice. The

provision of services to adolescents, although it can

be assisted by support from the Federal Government,

is ultimately a local issue. In addition, some Federal

IW3ee app. C, ‘‘Issues Related to the Lack of Information About Adolescent Health and Health and Related Services.’

1~A cen~~ F~er~ locus for ~ole~ent health issues would provide an appropriate organizational w%@ thu@ which to Wlkt ~d di.$wtite

such data (see Major Option 2, Strategy 2-1 on creating a locus for a strong Fedeml role in addressing adolescent health issues).
Summary and Policy Options . I-75

grant programs relevant to adolescent health issues

are based at least in part on the demonstration of

need in the local community. Answers to questions

such as which adolescents are using alcohol, tobacco, and illicit drugs; how many (and which)

adolescents have mental disorders; how many (and

which) adolescents use or need contraception, become pregnant, or are parents cart serve as a guide to

the placement of resources. To assist local communities with their planning, and potentially make the

Federal grantmaking process more equitable, Congress could consider the following strategy.

Strategy 2-4b: Support and encourage local

efforts to collect adolescent health information

that will be, at least in part, able to be compared

to national level data.135

There are several potential barriers to expansions

in the collection and analysis of information pertinent to adolescent health, both at the national and

local levels. First, data collection is expensive and

would almost certainly require additional budgetary

support. ’36

Second, questionnaires relying on self-reports are

the most common means of collecting information

on adolescent health status and health utilization,

perhaps because they are among the least expensive

alternatives. However, there is considerable concern

about the reliability and validity of self-report data.

This may be particularly true for: 1) adolescents,

who as a group may be more likely than other age

groups to respond in a socially desirable, rather than

an objectively true, manner (42,85); and 2) for

tracking trend data in those behaviors that vary over

time in social acceptability (e.g., sex, contraceptive

use, drug use). Alternative means of collecting data

from adolescents, or making concerted efforts to

verify information amassed through self-reports,

will be necessary.

Third, certain topics (e.g., suicide, drug use,

sexual activity) are considered quite delicate. For

economic reasons (e.g., real estate values, school

Photo credit: Education Week

Congress could support and encourage efforts to collect

local data that will be able, at least in part, to be compared

to national data

enrollments), local jurisdictions and specific schools

may be reluctant to collect data suggesting that

adolescents in their communities are troubled or

engaged in behaviors that may meet with social

disapproval. Also, there is typically some concern

that adolescents may be troubled by the asking of

some questions or actually driven to engage in

certain behaviors through the power of suggestion.

There is no hard evidence to support that the raising

of an issue in a questionnaire leads to engagement in

ls~For ~-pie, ~c youth Wsk Be~vlor~ S-ey, ~~ch w= being designed by a stee~ committ~ Suppfied by centers for Disease Control in

DHHS, will be administered at the National, State, and local levels, Certain core items will be constant across localities, and localities will have the option

to add spedlc items of particular importance. In this way, a core of information wilt be available nationally, and localities will have information of

importance to them as well as national comparative data (277). Similarly, the Young Americans M called for States wishing to apply for formula grants

for the purpose of improving the coordination of semices provided to childreq youfi and families, to prepare reports with detailed information gathered

by the State on young individuals and the families of such individuals concerning: 1) age, sex, race, and ethnicity; 2) residences; 3) incidence of

hopelessness; 4) composition of families; 5) economic situations; 6) incidence of poverty; 7) experiences in care away from home; 8) heal~ 9) violence

in homes or communities; 10) nature of their attachment to school and work 11) dropout rates; 12) character of the communities in which they reside

(Public Law 101-501, Title KX, Subtitle A, Chapter 2, Sec. 931).

13~~ ~ditio~ it my ~uire. IT- for additional researchers trained to work tith adolescent -ndents.
I-76 ● Adolescent Health—Volume I

a proscribed or dangerous behavior, 137 but these

concerns may be a function in part of communities

not knowing how to proceed when they do find they

have a problem. Therefore, it is important that local

data be allowed to be collected anonymously if need

be (so that individuals, individual schools, and

perhaps individual communities are not able to be

identified) and that they not be collected in isolation

from other efforts designed to deal with adolescent

health concerns.138

Strategy 2-5: Congress Could Create a Locus for a

Strong Federal Role in Addressing Adolescent

Health Issues and Invigorate Traditional Federal

Activities in Program Development, Research, and

Data Collection

Restructuring Federal adolescent health efforts so

that there is a more central locus for coordination

would not by itself address current deficiencies in

the traditional Federal activities related to program

development, research, and data collection. Thus, a

more ambitious, and potentially effective, approach

would be to combine Strategies 2-1 through 2-4.

Major Option 3; Congress Could Support Efforts

To Improve Adolescents’ Environments

The Nation’s approach to addressing the health

problems of adolescents is often skewed toward

efforts designed to convince adolescents to change

their own behavior. Teaching adolescents to behave

in ways that are socially acceptable, life-prolonging,

and otherwise health promoting is, of course,

important. But in the Nation’s realization that

behavior affects health (e.g., 260), the importance of

the social environment139 in influencing behavior

and otherwise contributing to health and health

problems has been neglected (230).

To illustrate this point consider the DHHS report,

Healthy People 2000. Healthy People 2000 is the

Nation’s most prominent statement on health objectives for the U.S. population and has numerous

health status and risk reduction goals related to

children, adolescents, and young adults (260).l40 By

comparison, the report sets forth relatively few goals

for “services and protection” that are specific to

adolescents. Box D presents year 2000 ‘ ‘service and

protection’ objectives related to adolescents.141

Major Option 1 (encouraging efforts to improve

adolescents’ access to health services) and Major

Option 2 (taking steps to restructure and invigorate

the Federal Government’s efforts to improve adolescents’ health) are consonant with a‘ ‘new approach’

to adolescent health concerns, in which adolescents

are provided with a prolonged protective and supportive environment and, it is hoped, adolescents

come to perceive that they are appropriately cared

for. Major Option 3 (supporting efforts to improve

environments for adolescents) requires strategies

outside of areas traditionally regarded as health

services (see table 8); they are designed to improve

i37A ~o~~lble ~xcwtion me tie fmd~gs ffom some ~cide prevention r~~ch s~di~ tit mass-orient~ suicide prev~tion ‘‘intel_Ventiom’ (e.g.,

the showing of films about adolescent suicide on television) have resulted in a d, but statistically signifkant, increase in adolescent suicide (see ch.

11, “Mental Health Problems: Prevention and Services,‘‘ in Vol. II) However, these were films and not questionnaires.

lsgFor exmple, the Natioti Commission on the Role of the School and the Community in Improving Adolescent H~t.h =ommmded tit

communities establish coordinating councils for childreu yout.1+ and families that develop local solutions to local problems (153).

13~e phy~i~ env~oment is ~w impo~~ but ~s Repofl foc~ on tie SOC~ env~nment. Otier mpofis by (YIX have focal on POtentid

health effects of the physical environmen~ although they have not focused specifically on adolescents. See for example: Catching Our Breath: Next Steps

for Reducing Urban Ozone (227); Technologies for Reducing Diom”n in the A4anufacture of Bleached Wood Pulp (226); Acid Rain and Transported Air

Pollutants: Implications for Public Poliqy (222); Neurotom”city:Identl fiing and Controlling Poisons of the Nervous System (23 1) and Complex Cleanup:

The Environmental Legacy of Nuclear Weapons Production (234).

l~e Hea/thy peep/e 2~~ rcw~ ida~l~ 32 ‘‘h~th s~~s’ @ “risk r~uction’ gofi for adolesc~~ ad young ad~ts, and 34 such gods for

children (260). A health status goal is defined in terms of a reduction in dea~ disease, or disability (e.g., ‘‘Reduce deaths among youth aged 15 through

24 caused by motor vehicle crashes to no more than 33 per 1(X),000 people” (Healthy People Objective Number 9.3b)). A n“sk reduction goal is defined

in terms of prevalence of risks to health or behaviors known to reduce such risks (e.g., ‘‘Increase use of helmets to at least 80 percent of motorcyclists

and at least 50 percent of bicyclists” (Healthy People Objective Number 9. 13)). It is important to note that DHHS notes that the report Healthy People

2000, although published by DHHS, ‘‘does not reflect the policies or opinions of any one organiza tie% including the Federal Government, or any one

individual’ (260). It is viewed by DHHS as ‘‘the product of a national process” (260). However, in transrm“King the report to the Secretary of DHHS,

the Assistant Secretary for Health committed the Public Health Service ‘‘to work toward achievement of these objectives [contained in Healthy People

2000] for the coming decade’ (260).

14 l~e &efim M~c~ A5wiation~s f cH~~ff you~ by the y= z~ ~oj~t’ pub~catio~ Healthy Y..wh 2f)00, p~vi@ a tier accounting

of the Healthy People 2000’s national health promotion and disease prevention objectives applicable to adolescents (defined by the American Medical

.4ssociation project as ages 10 through 24) (6). The American Medical Association publication excerpted objectives fi-om the DHHS publication Healthy

People 2000 (260) pertaining to all or part of the age group 10 to 24. In additio~ the American Medicat Association publication includes “Additional

Objectives” culled from Healthy People 2000, organized according to roles for “professionals in heatth care, educatio~ community, and government

contexts” (6).
.-

Summary and Policy Options . 1-77

Box D—Healthy People 2000 Service and Protection Objectives That Pertain to Adolescents

Healthy People 2000 is the Nation’s most prominent statement on health objectives for the U.S. population.

This report, published by the U.S. Department of Health and Human Services (DHHS) in 1990, contained a number

of health status and risk reduction goals for adolescents but relatively few service and protection objectives related

to adolescents. Preventive services include counseling, screening, immunization, or chemoprophylactic interventions for individuals in clinical settings, and health protection objectives are those environmental or regulatory

measures that confer protection on large population groups. In its lists of objectives by age group, DHHS combined

services and protection objectives.

Some year 2000 service and protection objectives identified by DHHS as related to adolescents would not

require changes in adolescents’ behavior, among them the following:

•

●

●

●

●

●

●

●

increasing the proportion of school lunch and breakfast services and child care food services with more

nutritious menus;

increasing the number of State and local tobacco-free indoor air laws;

eliminating or severely restricting tobacco product advertising and promotion to which youth are likely to

be exposed;

increasing the number of State laws to restrict minors’ access to alcohol;

increasing restrictions on promotion of alcohol to young audiences;

extending emergency room protocols for identification of suicide attempters, victims of sexual assault, and

child abuse victims;

removing financial barriers to immunizations; and

increasing the proportion of primary care providers who provide age-appropriate preconception care and

counseling.

Other service and protection goals targeted to adolescents would require changes in adolescent behavior,

among them:

● increasing the proportion of children and adolescents who participate in daily school physical education;

● increasing the proportion of school physical education class time that students spend being physically active;

and

● increasing the proportion of 10- to 18-year-olds who have discussed sexuality with their parents and/or

received sexuality information through a parentally endorsed source.

A number of service and protection objectives were not identified by DHHS as targeting adolescents but could

potentially affect adolescents, among them:

●

●

●

●

●

●

●

●

increasing the availability and accessibility in the community of physical activity and fitness facilities;

increasing by 100 percent the availability of processed food products that are reduced in fat and saturated

fat;

increasing the proportion of restaurants and institutional food service operations that offering identifiable

low-fat, low-calorie food choices;

ensure access to alcohol and drug treatment programs for traditionally undersexed people;

increasing driver’s license suspension/revocation laws or programs of equal effectiveness for people

determined to have been driving under the influence of intoxicants;

increasing the proportion of pregnancy counselors who offer positive, accurate information about adoption

to their unmarried patients with unintended pregnancies;

increasing services for human immunodeficiency virus (HIV) infection and sexually transmitted diseases

(STDs);

increasing the proportion of providers of primary care for children who include assessment of cognitive,

emotional, and parent-child functioning, with appropriate counseling, referral, and followup, in their clinical

practices;

IW health promotion and disease prevention ob~ves are organized initially by strategy (e.g., hdh prOmOdOtL h~th protio~

preventive services, and surveillance and data systems), not by population group (m). ~CQ a MP~@ s=tionof ~ff~thypeople 2~0 vfi

lists the objectives as tbey pertain to certain‘ age groups (i.e., childrerL adolesccds and young adults, adults, and older adults) and “speciai”

populations (i.e., people with low income, blacks, Hispanics, Asians and Pacilic Islanders, American Indians and Native Ameriearm and people

with disabilities).

Conthed on next page
1-78 ● Adolescent Health-Volume I

I

Box D-Healthy People 2000 Service and Protection Objectives That Pertain to Adolescents—

●

●

●

Continued

increasing the number of States in which at least 50 percent of children identified as physically or sexually

abused receive physical and mental health evaluation with appropriate followup;

increasing the number of States requiring safety belt and motorcycle helmet use for all ages;

enacting laws requiring that handguns be made more difficult to discharge by children;

extending to 50 States emergency medical services and trauma systems linking prehospital, hospital, and

rehabilitation services;

performing testing for lead-based paint in homes built before 1950;

extending to to long-term institutional facilities (including juvenile homes and detention facilities) the

requirement that oral examinations and services be provided no later than 90 days after entry into these

facilities; and

extending requirement of the use of effective head, face, eye, and mouth protection to all organizations

sponsoring sporting and recreation events that pose risk of injury.

SOURCE: office Ofmchndogy Ass txtuneq 1991, batlcd on U:s. ~t ofllcalth and Human $krvi@& Public Hcnltb Semiq Healthy

Peop!e 2(MO: National Health Promotion and Disease Prevention Objectives, Cmfacmc edition (w~ “ DC: scptember

1990).

the social environment for adolescents, with the

goals of promoting health and protecting adolescents from adverse environments.

One strategy would be for Congress to take steps

to increase support to families so that they can play

their rightful and important role in adolescents’

development and health (Strategy 3-l). Another

strategy would be for Congress to take steps to

reduce the adolescent death and injury toll from

firearms by reducing adolescents’ access to firearms

(Strategy 3-2). A third strategy would be for

Congress to support the expansion of healthpromoting recreational opportunities for adolescents

(Strategy 3-3). A fourth strategy would be for

Congress to monitor the effect on adolescents of the

recently passed National and Community Service

Act (Public Law 101-610) (Strategy 3-4).

Strategy 3-1: Congress Could Take Steps To

Increase Support to Families of Adolescents

Appropriate roles for parents change during

adolescence, but changing relationships between

adolescents and parents should not obscure the fact

that parents remain essential to healthy adolescent

development. 142 Unfortunately, many current policies provide little support for parents to take an

active and appropriate role in the lives of their

Photo credit: Capitol Hill Arts Workshop, Washington, DC

Many current policies provide little support for parents to

take an active and appropriate role in the lives of their

adolescent children.

adolescent children.143 A recent review found that,

of the four parental functions important for the

socialization, development, and well-being of adolescents (providing basic needs, protection, guidance, and advocacy), existing parental support

programs were most likely to emphasize the guidance function, and none addressed the basic resource

provision function of parents (192). Only a handful

of parental support programs addressed the personal

or developmental needs of adults who are raising

adolescent children (192). Further, OTA has observed that much of the theorizing and planning
Table 8-Strategies for Major Option 3: Congress Could Support Efforts To Improve Adolescents’ Environments

Rough estimate of

Time for cost (direct) to

Strategy Policy issue addressed expected impact Federal Government

Strategy 3-1: Congress could take steps to increase support to

famliles of adolescents.

Strategy 3-2: Congress could take steps to support additional

limitations on adolescents’ access to firearms.

3-2a: Act to place additional limitations on adolescents’ access to firearms.

3-2b: Fund a study to determine how to further restrict

adolescents’ access to firearms.

Strategy 3-3: Congress could support the expansion of appropriate recreational opportunities for adolescents.

Strategy 3-4: Congress could monitor the effects on adolescents

of the Implementation of the National and Community Service

Act of 1990.

Parents are legally responsible for their

adolescents, are often needed to accompany adolescents for the receipt of health

services, and play an essential role in

adolescents’ optimal development.

Suicide, infliction of injury and death by

adolescents.

Suicide, infliction of injury and death by

adolescents.

Appropriate use of discretionary time;

potential for adult guidance; possible reduction of subjective distress; opportunities for learning life-skills and social

competence; opportunities for work (community service); possible reduction in

substance abuse, especially among disadvantaged adolescents.

Appropriate use of discretionary time;

adult guidance; improved sense of citizenship. Would help to ensure that the

“quantifiable measurable goals” to be

included in local grant applications are

stated and measured for adolescents,

including the economically and educationally disadvantaged youths targeted in

the legislation; and would thus give a

sense of how well adolescents are

addressed in the implementation of the

legislation.

Depends on strategy

adopted

Medium term

Longer term

Medium to longer term

Immediate

Low to medium, depending

on strategy

Low

Medium

Depends on Federal

contribution

Low

SOURCE: Office of Technology Assessment, 1991.
i-80 ● Adolescent Health-Volume I

about the role of the family and family support has

focused on the needs of younger children.145

Congress could take concrete steps to enhance the

abilities of parents to provide for the basic needs of

their adolescent children (e.g., through child allowances, tax credits, additional support for postsecondary education, and child care appropriate for adolescentsl46). In addition, Congress could take steps to

enhance the availability of parents to be involved in

the lives of their adolescent children (e.g., by

promoting flexible worktime so that parents can be

home after school, attend teacher conferences, and

participate in school activities).

The changing developmental status of individuals

during adolescence means that direct application of

the kinds of family support features proposed or

enacted for families with younger children would

not be appropriate for families with adolescents. In

general, the design of appropriate family support

policies for families with adolescents might be

preceded by an analysis of the practices of other

developed countries and should seek the participation and advice of adolescents and their families.

In addition to concrete support, a clear need for

many parents is for accurate information about the

challenges of parenting adolescents. The need to

develop innovative methods to disseminate information about appropriate parenting strategies during

adolescence was noted earlier (see Major Option 2,

Strategy 2-2a and table 7, above), Because the

knowledge base on appropriate parenting is still

slender with respect to nonwhite, non-middle-class,

and nonurban families (192), it would be important

to accompany such information dissemination with

training and evaluation, as well as to expand the

research base on how appropriate parenting of

adolescents may differ for lower socioeconomic

and/or racial and ethnic minority adolescents, and

those in rural areas.

Strategy 3-2: Congress Could Take Steps To Support

Additional Limitations on Adolescents’ Access to

Firearms

Access to firearms for persons of all ages is one of

the most hotly debated issues in the United States

(214). It seems universally agreed, however, that it

is unwise for minors to have unlimited access to

firearms. Despite this recognition, and associated

Federal legal limits on the sale (but not possession)

of firearms to minors,

147 U.S. adolescents do have

access to firearms, which they use for destructive

purposes (e.g., suicide, homicide, other violence) or

to harmful ends (e.g., accidental injuries). l48 I n

addition, adolescents are increasingly the victims of

firearm-related homicides committed by persons of

all ages.149

Much needs to be determined about how adolescents gain access to firearms, particularly those

firearms that are used without parents’ knowledge

and for illegitimate purposes (e.g., see 336). 150

Nonetheless, international comparisons of youth

ldsFor e~ple, tie Ftiy and Medical ~ve AC~ which was passed by the IOlst Congress but vetoed by the Fresident and IIOt overridden by tie

Congress (H.R. 770), applied primarily to family leave for newborn or adopted children, although it would have covered unpaid family leave for seriously

ill children.

lqbs~ategles for r~r=tion~ and yOUth service opportunities that are appropriately overseen by adults (Strategim 3-3 and 3-4 bdow) are relevm~ tO

child care for adolescents.

Id?some SUte laws aISO tittie ownership, purchase, and possession of guns by minors. The laWS vw widely by State.

148See & 5, ‘‘Accidenti Injuries: Prevention and Services”; ch. 11, “Mental Health Problems: Prevention and Semices ”; ch. 13, “Delinquency:

Prevention and Services,” in Vol. II.

ldssee Ch. 13, 1‘De@uency: Prevention and Services, ’ in VOI. ~.

l-or exmple, ~ea/rhy People Z(IOO gave as gods for reducing violent and abusive behavior 20 percent reductions in: 1) ~ Proportion of w~pons

(i.e., not limited to gum) that are inappropriately stored and therefore dangerously available, and 2) the incidence of wtzqxm-carrying by adolescents

aged 14 through 17 (260). DHHS noted, however, that baseline data for the fiist objective would not be available until 1991, and for the second objective,

1992 (260), (The only apparent objective speciilc to fmearms was a ‘‘services and protection” goal related to unintentional injuries (not violent and

abusive behavior) that, by the year 2000, 50 States would have laws ‘‘requiring that new handguns be designed to minimize the likelihood of discharge

by children” (260).)

The National Adolescent Student Health Survey asked only limited questions about adolescents’ access to firearms (10). Even data about the causes

of injuries from hospital emergency rooms are limited (see ch. 5, “Accidental Injuries: I%vention and Services, ’ in Vol. II). ‘I& U.S. Consum erProduct

Safety Commission collects information about adolescents’ emergency room visits associated with numerous consumer products, but not about

emergency room visits related to guns (see ch. 5, “Accidental Injuries: Prevention and Semices, “ in Vol. II). Wright and Rossi noted in their book

summarizing their survey of weapons acquisition among convicted felons doing time in State prisons that ‘‘some of the most important questions [on

weapons, crime, and violence in America] have. . barely been researched” (336). Among these important questions tbey included ‘the question of how,

where, and why crimimd s acquire, carry, and use fuearms. ’ Their own survey could not answer this question regarding juvenile offenders because

relatively few juvenile offenders were serving time in the State prisons for violent offenders that cooperated with the Wright and Rossi researc h pruject

(336).
Summary and Policy Options . 1-81

homicide rates, and data about the level of access to

firearms by U.S. adolescents, suggest that one or

both of the following strategies maybe warranted.

Strategy 3-2a: Act to place additional limitations on adolescents’ access to firearms.

Strategy 3-2b: Fund a study to determine how

to further restrict adolescents’ access to firearms.

Analysis of specific actions that Congress (and

others) could take to specifically limit adolescents’

access to firearms would require analysis beyond

that which was possible in this Report (e.g., an

in-depth analysis of the ways in which adolescents

legally and illegally gain access to firearms; legal

issues in limiting access).151

Because the sale of firearms to adolescents is

already illegal under Federal law, it can be assumed

that many adolescents obtain access to firearms

purchased by adults. Placing further limitations on

adolescents’ access may affect adults’ access to

firearms, and efforts to limit adult access to firearms

raise constitutional issues and are politically contentious (see, e.g., 214). Half of U.S. adults polled

report that they own at least one gun, and half keep

guns in their homes (217). Further, the issue of

whether the availability of guns is a major or

substantial factor in the violent crime rate152 (or in

adolescent suicide

153 ) has not been settled to

everyone’s satisfaction (214). Steps that could limit

adolescents’ access to firearms, while not unduly

affecting adult access,154 include requirements for

adults with firearrns to keep firearms securely away

from adolescents (and younger children) (e.g.,

locked up in the home, or, for firearms used only for

hunting, locked up in a community facility), penalties for adults whose adolescent dependents are

harmed by firearms, and trainin g and licensing

requirements for adolescent use of firearms (e.g., for

hunting). Adults, as well as adolescents, need to be

educated that ammunition should be stored in a

location separate from guns.

Strategy 3-3: Congress Could Support the

Expansion of Appropriate Recreational

Opportunities for Adolescents

Adolescents need health-promoting recreational

opportunities. Although no national survey has been

conducted on the kinds of recreational opportunities

adolescents would like to have, reasonable options

for recreation include swimming pools, running

tracks, basketball courts, ball fields, gymnasiums,

billiards, ping pong, other indoor sports, music,

dances, and a place to socialize.155

Federal support could be provided through seed

moneys or matching grants to local recreation

departments and private organizations that can

demonstrate a strategy appropriate for adolescents,

including adolescent participation and sufficiently

trained adult supervision.

On the face of it, increasing recreational outlets

for adolescents may seem costly. On the one hand,

supporting additional recreational outlets may rarely

involve the construction of new buildings.156 Rather,

available facilities such as school buildings could be

adapted to be compatible with the needs of adolescents (e.g., remain open at appropriate hours and

Photo credit: Katherine Criss, New York, NY

Adolescents need health-promoting recreational facilities

and activities ranging from swimming pools, gymnasiums,

and ball fields to dances and other social activities.

15 IOTA is cwently developing a background paper on automatic f~~ purchaser checks.

152$ec ch. 13, ‘ ‘Delinquency: Prevention and Services, ’ in VO1. ~.

153See ch. 11, “Mental Health Problems: Prevention and Services, ” in Vol. 11.

1540TA dld not as~e~s tie wisdom of or potenti~ heal~ effec~ of ~v~sal gUII Cotlmol (i.e., fOr all ageS).

155~e D~S ~ubllcation Healthy people 2000 rmomend~ &reaseS in comm~~ ava~ablli~ and accessiblli~ of physical aCtiVity and fitieSS

facilities (hiking, biking, and fimess trails; public swi mrning pools; acres of park and recreation open space) in order to improve the physical fimess of

U.S. citinms (Objective 1.1 1) (260). Data on facility availability per 1,000 population cited in Healthy Peep/e 2000 were not adolescent-specific.

ISbsome communities, however, may not have adequate facilities.
1-82 Adolescent Health-Volume I

install appropriate equipment). On the other hand,

such adaptations, and requirements for appropriate

adult supervision, may involve upfront and continuing costs (e.g., training, continuing education),

Strategy 3-4: Congress Could Monitor the Effects on

Adolescents of the Implementation of the National

and Community Service Act of 1990

As described in this Report, 157 the l0lst Congress

passed a 1990 law designed to enhance opportunities

for national and community service for all U.S.

citizens, particularly the disadvantaged. In presenting the rationale for the legislation, the senatorial

authors of the legislation argued in part that (S. 1430,

101st Congress, 2d session):

(1) service to the community and the Nation is a

responsibility of all citizens of the United States,

regardless of the economic level or age of such

citizens;

(2) citizens of the United States who become

engaged in service at a young age will better

understand the responsibilities of citizenship and

continue to serve the community into adulthood;

(3) serving others builds self-esteem and teaches

teamwork decision making, and problem-solving;

(4) the 70,000,000 youth of the United States who

are between the ages of 5 and 25 offer a powerful and

largely untapped resource for community service;

(5) conservation corps and human service corps

provide important benefits to participants and to the

community;

(6) the Volunteers in Service to America Program

is one of the most cost effective means of fighting

poverty in the United States. . .

Many of the activities and program requirements

authorized by the National and Community Service

Act of 1990 are particularly relevant to adolescents, 158 including economically and educationally

disadvantaged adolescents. 159 The legislation also

requires that quantifiably measurable goals be included in local grant applications (S.1430, Title I,

Photo credit: Youth Services of America, Washington, DC

It is likely that adolescents who serve others can build

self-esteem and learn teamwork, decisionmaking, and

problem solving.

Subtitle B, Sec. 1 lo). While the tota l

amounts authorized for programs with a considerable emphasis on adolescents are not very large,l60

the legislation does begin to address many of the

concerns about adolescent rolelessness and preparation for the future expressed by numerous observers

ISTSee ch. 4, ‘‘Sch~ls and Discretionary Time, h VOI. H.

158 Ages oro~errelevmt ~ge-relatedc~ctefistics ~ere~c]ud~ tie Schml ad Commtity B~~ S-ice pofion ~ifle I, Subtitle B), forelemenUwy

and secondmy school students and out-of-school youti the American Conservation and Youth Corps (Title I, Subtitle C), for 15- to 25-year-olds; and

the National and Community Service Program (Title I, Subtitle D), for ages 17 and older. Youth Community Semice programs are required to include

an age-appropriate learning component.

159$ ‘T. be Cllglble t. remlve a ~at [under Tifle I, subdue B, School ad comm~i~ B~ed Service] a s~te, . .M1 prqwe md 5ubMi~ to the

Commission [on National and Community Service, established under section 190 of the act], an application. . including a description of the manner in

which. .econornically and educationally disadvantaged youths, including individuals with disabilities, youth with limited basic skills or learning

disabilities, and youth who are in foster care, are assured of service opportunities” (S. 1430, Title I, Subtitle B, Sec. 113).

l~or Cxmp]e, tie fo]lo~g ~o~~ wme au~ori~d to be appropriated for fiscal year 1991: $10 million for the Schwl md comm~ty Bu~

Service provisiou $14 million for the American Conservation and Youth Corps; and $14 million for National and Community Service. Fifty pereent

increases for each program were authorized to be appropriated for fiscal year 1992.
.

Summary and Policy Options ● 1-83

(160, 330). It is too early to judge the effectiveness

of the legislation in improving the lives of adolescents, but Congress could encourage the Commission on National and Community Service (also

established by Public Law 101-610), to evaluate

systematically the impact on adolescents in the

Commission’s Report to Congress.

Summary of Major Policy OptIons

In conclusion, three major policy options suggest

themselves as a result of OTA’s analysis of adolescent health:

1. Congress could adopt strategies to improve

adolescents’ access to appropriate health

and related services;

2. Congress could adopt strategies to restructure and invigorate the Federal Govern -

ment’s efforts to improve adolescents’

health; and

3. Congress could adopt strategies to improve

environments for adolescents.

It is important to note, however, that apart from

whatever specific strategies the Federal Government

may adopt to improve adolescents’ health, there is

a need for a basic change in approach to

adolescent health issues in this country. Even if all

the specific policy changes suggested by OTA’s

analysis were to be implemented without a basic

change in approach, the whole would be less than the

potential sum of the parts. Instead, both the major

options and the specific options (discussed below)

were developed using a basic guiding principle,

which should not be forgotten as specific changes

are considered and, perhaps, implemented. That

basic guiding principle is that a more sympathetic

and supportive approach to adolescents is needed.

This approach could follow the model of authoritative parenting, which combines warmth, democracy,

and demandingness in a prolonged protective environment.

Specific Findings and Policy Options

This section discusses specific findings and additional policy options related to topics addressed in

particular chapters of OTA’s adolescent health

Report:

. the conceptualization of adolescent health (ch.

2),

. parents’ and families’ influence on adolescent

health (ch. 3),

●

●

●

•

●

●

●

schools and discretionary time (ch. 4),

prevention and services related to selected

adolescent health concerns (chs. 5 through 14),

the delivery of primary and comprehensive

health services to adolescents (ch. 15),

adolescents’ financial access to health services

(ch. 16),

adolescents’ legal access to health services (ch.

17),

issues in the delivery of services to specific

groups of adolescents (e.g., poor adolescents,

racial and ethnic minority adolescents, and

rural adolescents) (ch. 18), and

the role of Federal agencies in adolescent health

(ch. 19).

Policy options in each of these areas are summarized in accompanying tables. These specific options

are permutations of the three major policy options

identified earlier:

1. improve adolescents’ access to health and

related services,

2. reconceptualize and invigorate Federal efforts

to improve adolescent health, and

3. foster environmental changes to improve adolescent health.

It is important to emphasize that the specific policy

options presented below (and above) are not intended as recommendations. OTA does not make

recommendations. The options here are merely

intended to illustrate a range of possible alternatives

that Congress may wish to consider in addressing

some of the adolescent health problems identified in

specific chapters of this Report. Each of the options

presented has pros and cons, and a full consideration

of these would be advisable prior to taking action on

any particular option.

The Conceptuallzatlon

of Adolescent Health (ch. 2)

In the process of testing formerly widely accepted

grand theories of adolescent development, researchers in adolescent development have found that

popular conceptions of adolescents as a group whose

behavior is overwhelmingly determined by “raging

hormones” and of adolescence as a period when to

be abnormal is normal are misguided (see, e.g., 62).

Further, these misconceptions are not benign: they

may have deleterious effects on attitudes towards

individual adolescents and, subsequently, on inter-
I-84 . Adolescent Health—Volume I.

Photo credit: Education Week

More appropriate conceptualizations of adolescent health

would include the most traditional definitions of health (i.e.,

the presence or absence of disease and disability);

consideration of adolescent behaviors; positive

components of health (e.g., social competence); health

and well-being from the perspective of adolescents

themselves; and social influences on health (e.g., families,

schools, communities, and policies).

actions with individual adolescents and on policy

and program development.

A more positive view of adolescents should not

obscure the fact that, as a period of life, adolescence

involves major physiological, cognitive, psychological, and social change, perhaps more so than at any

other time of life. OTA finds that as a society, the

United States provides little help to individuals as

they try to cope with the normal changes of

adolescence. For example, societal expectations for

adolescents are inconsistent and may simultaneously restrict adolescents unnecessarily and demand

from them an unrealistic level of maturity.

Specific options related to the conceptualization

of adolescent health are presented in table 9.

Parents’ and Families’ Influence

on Adolescent Health (ch. 3)

Contrary to theories that the goal to strive for

during adolescence is an individual’s complete

Table 9-Specific Options Related to Conceptualizations

of Adolescent Health (ch. 2)

Option 1: Improve adolescents’ access to health and related

services.

. Support changes in health education efforts so that adolescents’ wants and needs are taken into greater consideration.

Option 2: Support Federal data collection and research.

Data collection:

. Support the collection of data that allow for differences that

occur during adolescence. This would require data from

larger samples of adolescents.

Research:

● Support research on normal adolescent development in poor

and minority adolescents.

SOURCE: Office of Technology Assessment, 1991.

independence from his or her family, families

continue to be of major importance to individuals as

they go through adolescence. If parents and families are to be a positive influence in adolescents

lives, however, they need to be available, and to

have accurate and useful information about

adolescent development and about family functioning appropriate to adolescents.

Parent availability is difficult to assess, because it

has both quantitative and qualitative aspects. Single

parents, parents who work full time, and parents who

do not live with their adolescent children maybe as

psychologically available to their children as some

parents who are frequently at home. However, one

would expect that not living with one’s child, being

a single parent, or working full time would all reduce

the amount of time that parents have available for

their adolescent children. On this account, many

adolescents and families may be at risk of missing

important positive parental guidance. Approximately

6 percent of adolescents (1.9 million) live in

households without either parent.161 Thirty percent

of adolescents ages 10 to 18 (9.3 million adolescents) live in households headed by a single parent

(1987 data (109)). Two-thirds of adolescents (17.5

million of those ages 10 to 17) live in households

where both parents (or a single parent) work full time

(245).

162 Anecdotal evidence suggests that other

family members are often not available to take up

some of the roles of parents.

Research suggests that parenting an adolescent

requires a different approach than does parenting a

younger child, but relative to the amount of guidance

Islsome of tie ado]~cents cout~ by me Census Bureau as living without either parent are adolescents who are married ad fiv@ with tieti pments.

162~~ch 1~, here ~ereappmx~tely 18.6 filfion~ami~y howehO/d~ ti~ adole~ent children ages 12 to 17 (247). Data are not readily available

on the number of families with children ages 10 through 18.
. . .. .... . —. —.

Summary and Policy Options ● 1-85

provided to parents of infants and young children,

little guidance is provided to parents as their children

mature into adolescence. Promising models of

parent-adolescent interaction are available, however: these models provide a combination of open

communication (give-and-take between parents and

adolescents) in an environment of consistent support

-and firm enforcement of unambiguous rules (13,198).

Families with such interactions tend to have adolescents with less susceptibility to antisocial influences, healthier forms of exploratory behavior,

greater social competence, and greater capacity for

cooperative or responsible social relationships (13,

81,93). 163

That relationships between some parents and

adolescents are not all that they should be is

suggested by findings--not widely recognized or

discussed—that the rate of maltreatment is more

prevalent among adolescents than among younger

children. In 1986, between 600,000 and 700,000

adolescents ages 10 to 17 were found to have been

maltreated (259). l64 165 But children’s protective

services have focused on early childhood abuse and

neglect, failing to provide adequate protection to

adolescent victims.

Another partial indicator of poor relations between adolescents and parents is the number of

adolescents in foster care. In 1985, approximately

120,000 adolescents were in foster care (330). Yet a

more serious indicator is the number of adolescents

who ‘‘run away’ or are ‘thrown away from home.

The number of homeless adolescents is not known,

but DHHS estimated in 1984 (on the basis of 1976

data) that 1 million adolescents are homeless (256).

Adolescents, more than younger children, can be

expected to be homeless as a result of running or

being ‘‘thrown” away.

Specific options related to providing support for

improving parents’ and families’ influences on

adolescent health, when such improvement is needed,

are presented in table 10.

Photo credit: Office of Technoiogy Assessment

There is some evidence that child protective services have

failed to provide adequate protection to adolescent victims

of maltreatment.

Schools and Discretionary Time (ch. 4)

Although little systematic empirical research has

been supported, the studies that have been conducted

suggest that academic and health outcomes of

adolescent students are influenced by school environments. Overall, school environments that facilitate adolescent well-being take the shape of small

(fewer than 1,000 students in the school, and 15 to

20 per class), comfortable, safe, intellectually engaging, and emotionally intimate communities.

Transitions are minimized, and when they must

occur, they are managed with a view toward meeting

the developmentally appropriate needs of adolescents. Teachers are encouraged to initiate and

develop new programs that are sensitive to the

diversity of their students. The curriculum responds

to individuality as well as to differences, while

developing a common knowledge base among

students in a particular school. Teacher, parent, and

student participation in decisionmaking is encouraged. Unfortunately, this combination of features

characterizes few schools, particularly those public

lbJFor a popul~zed ~ide to parenting that is in accordance with the research findings, see McBride (130).

164~e ~m~r of ~~eated ~do]=cents differs depend~g on use of tie ori@ (1980) def~tions or tie use of the revtsc.d ( 1986) definitions of

maltreatment (see ch. 3, Parents’ and Families’ Influence on Adolescent HealtlL’ in Vol. II). The revised deftitions, which counted maltreatment that

resulted in endangerment as well as demonstrable hanq and teenage as well as adult perpetrators, result in higher estimates. Although there are

differences by age and type of maltreatment within adolescence, the general order of prevalence in 1986 was: 1) physical abuse, 2) educational neglect

(which was the leading form of maltreatment for older adolescents), 3) emotional neglec~ 4) emotional abuse, and 5) sexual abuse. OTA was not able

to calculate the rate of physical neglect using the information available in the report from the National Center on Child Abuse and Neglect (within DHHS).

165 Ado]eKents were, however, more 1&ely [O suffer mode~te inj~es and f~ INs ~ely tO s~fer fat~itics due tO titr~tment m Wefe yOWlgtY

children (259),
I-86 ● Adolescent Health-Volume I

Photo credit: Office of Technology Assessment

Many schools serving socioeconomically and

educationally disadvantaged students lack the

combination of features that promotes adolescents’

well-being.

schools serving socioeconomically and educationally disadvantaged students, many of whom are

racial and ethnic minorities. Instead, the larger, often

impersonal, schools that these students attend have

been found to be associated with higher rates of

retention in grade, suspensions from school, discipline and crime problems, lowered social cohesion,

more negative student attitudes, and greater student

passivity (including lower participation in school

activities, and less interaction with faculty).

Specific practices such as tracking and ‘‘teaching

to the test’ for minimum competency testing have

been associated with lowered levels of academic

achievement, retention in grade, and school dropout,

especially for low income racial and ethnic minority

students. Although school practices and policies are

rarely investigated for their direct links to adolescent

health and well-being, studies have shown that lower

Table 10-Specific Options Related to Parents’ and

Families’ influence on Adolescent Health (ch. 3)

Option 1: Improve adolescents’ access to health and related

services.

● Support the dissemination to parents of accurate and useful

information about adolescent development and appropriate

parenting (e.g., following authoritative and democratic family

models).

● Support access to individual and family therapy services for

adolescents from abusive or dysfunctional families and

families with stepparents.

Option 2: Support Federal data collection and research.

●

●

●

●

Support ‘additional research on parenting styles and their

effects on adolescent health and development, especially

among poor adolescents and racial and ethnic minority

adolescents.

Support demonstration projects for alternative child protection approaches for adolescents (e.g., therapeutic foster

care, transitional living).

Support demonstration projects to determine and change

attitudes of health and related service providers so that

families come to be treated more respectfully in their

interactions with public and private agencies.

Support research on the relationship between adolescent

maltreatment and health problems” such as depression,

alcohol and drug abuse, suicide attempts, and other selfdestructive behaviors.

Option 3: Foster changes In adolescents’ environments.

● Support family and parental leave including flexible time

arrangements to promote appropriate parental involvement

in their adolescents’ lives.

SOURCE: Office of Technology Assessment, 1991.

grades are associated with violence toward school

property, other delinquency, and pregnancy. Students who are retained in grade school are more

likely to drop out of school before graduation. In

turn, school dropout is associated with high rates of

subsequent poverty and unemployment, underemployment, diminished earnings, and adolescent pregnancy and parenting.

Adolescents, particularly females, can be particularly harmed by the transition from elementary to

middle or junior high school grades, if such transitions are not handled well in the middle school

setting (29). The environment of the typical junior or

middle school adolescent has been found to clash

with early adolescents’ needs for autonomy, their

budding cognitive abilities to think at an abstract

level, their heightened needs for intimacy, and their

heightened self-consciousness.

Teachers’ attitudes and parental involvement are

critical links in the relationships between school

policies and environments and health outcomes for

adolescents. Teachers’ attitudes toward students

tend to be more positive in schools that are smaller,

use decentralized governance and participatory deci-
m---

Summary and Policy Options .1-87

Photo credit: Kevin O’Malley, Los Angeles, CA

Adolescents, particularly females, can be harmed by the

transition from elementary to middle or junior high school

if such transitions are not well handled in the

middle school setting.

sionmaking, and rely less on standardized testing.

Parental involvement in schools has been shown to

be related to increasing the responsivity and efficiency of schools and to fair treatment of students,

but the evidence on academic achievement is mixed.

Some interventions have shown increases in

tolerance across racial groups and improvements in

the self-esteem or academic achievement of racial

and ethnic minorities; these interventions include

exposure to persons of differing cultural backgrounds, learning in mixed ability groupings, a

multicultural curriculum, bilingual education, and

school-based collaborations with minority communities.

Much of adolescents’ time is spent away from

school, The scarce data that are available suggest

that sufficient opportunities do not exist for adolescents to spend their discretionary time in ways that

are attractive and satisfying, conducive to healthy

development, and acceptable to the adult community. The problem has been found to be worse in poor

than in middle-class communities.

The Federal share in funding for schools (6.3

percent of public school revenues in 1988) rose until

1980, when it began to fall again (249). Financial

and programmatic support for recreation and youth

service activities from Federal, State, and local

governments, and the private for-profit sector, has

been meager and fragmented. Federal support for

4-H clubs and, more recently, the National and

Table Ii-specific Options Related to Schools and

Discretionary Time (ch. 4)

Option 1: Improve adolescents’ access to health and related

services.

●

●

●

●

●

Re-evaluate policies and practices associated with tracking

students by academic performance.

Increase Federal support for schools to mitigate disparities in

community tax bases.

Support promising interventions such as peer tutoring,

decentratized decision making, and innovative approaches to

parental involvement while including rigorous evaluations of

these interventions.

Support education for students and school and youth

services personnel on topics in adolescent development.

Promote the widespread dissemination, transfer, and application of knowledge about adolescent development, “and

recreational and community service programs for adolescents.

Option 2: Support Federal data collection and research.

Data collection:

. Collect data on the availability y of school-based resources

and facilities that could be used by adolescents in their

discretionary time.

● Support the collection of data on the availabilit y of recreational, youth service, and community service outlets for

adolescents, especially those living in poor communities.

Research:

●

●

●

Support rigorously evaluated demonstration projects on the he

impact of multicultural and bilingual curricula on adolescent

health outcomes such as self-esteem and academic achievement.

Support research on the features of recreational and youth

and community services activities that both attract adolescents and are health-enhancing.

Support a multisite demonstration project of efforts to

improve academic achievement and school retention for

minority, poor, and academically marginal students, using

factors that are known or appear to be effective in improving

health outcomes as a framework for intervention. Support

research on adolescent preferences for recreational, community service, and youth services outlets in poor, minority,

and rural communities.

Option 3: Foster changes In adolescents’ environments.

● Support the expansion of recreational (e.g., pools, gymnasiums, parks) and community service programs (e. g., peer

tutoring) in elementary, middle, junior high, and senior high

schools, and in communities with large numbers of minority

and/or poor adolescents. Especially support the involvement

of adolescents in the design and implementation of these

programs and the provision of incentives for adolescent and

adult participation.

SOURCE: Office of Technology Assessment, 1991.

Community Service Act of 1990 (Public Law

101-610) is an exception.

Specific options related to schools and discretionary time are presented in table 11.

Prevention and Services Related to Selected

Adolescent Health Concerns (chs. 5 through 14)

This section discusses specific findings and policy options related to the prevention and treatment of

specific adolescent health problems:
.

i-88 . Adolescent Health--Volume I

●

●

●

●

●

●

●

●

●

●

accidental injuries (ch. 5),

chronic physical illnesses (ch. 6),

nutrition and fitness problems (ch. 7),

dental and oral health problems (ch. 8),

AIDS and other sexually transmitted diseases

(STDs) (ch. 9),

pregnancy and parenting (ch. 10),

mental health problems (including suicide attempts and suicide) (ch. 11),

alcohol, tobacco, and drug abuse (ch. 12),

delinquency (ch. 13), and

hopelessness (ch. 14).

s ummary information on the prevalence of these

problems and the adolescents most affected is

presented in appendix B, “Burden of Health Problems Among U.S. Adolescents,” in Volume HI.

Accidental Injuries (ch. 5)166

Since 1970, the accidental death rate for U.S.

adolescents has declined (figure 3 in “Major Findings”), although not to the levels seen in the 1950s

(65,184). Accidental injuries today are responsible

for more deaths to U.S. adolescents than any other

cause, representing more than half of all deaths to

persons ages 10 to 19 in 1987 (290). In 1987, 10,658

adolescents ages 10 to 19 died as a result of an

accidental injury.

Vehicle-related (motor and nonmotor vehicle)

accidents account for almost three-fourths of accidental deaths among persons ages 10 to 19; other

important causes of accidental deaths in this age

group are drowning accidents (8 percent of accidental deaths), and firearm accidents (4 percent of

accidental deaths). Exposure of adolescents to firearms appears to be quite high. Over 40 percent of the

8th and l0th graders surveyed in the National

Adolescent Student Health Survey reported that they

had used a gun during the past year; of these, over 40

percent had used a gun more than 10 times (10),

Many U.S. adolescents experience accidental

injuries that are not fatal but cause visits to

Photo credit: Bethesda-Chevy Chase Rescue Squad

Efforts to develop a national strategy to prevent accidental

injuries have been hampered in part by a lack of

information about the causes of such injuries and the

effectiveness of interventions to prevent injuries or reduce

their severity. To address the lack of information about the

causes and extent of injuries among adolescents,

Congress could support the collection of data that

include information about levels of exposure to risks.

physicians’ offices or hospital emergency rooms,

temporary or permanent disability, restrictedactivity and school-loss days, and other problems.

Comprehensive national data on nonfatal accidental

injuries are not available, l67 but sports injuries

incurred while playing basketball, football, or baseball, or riding a bicycle accounted for 772,000

emergency room visits by adolescents in 1988 (239).

Adolescent males, particularly males ages 15 to

19, are- at higher risk for all leading accidental

injuries and deaths than adolescent females, but the

precise reason (e.g., differing exposure rates) cannot

be ascertained from available data. White male and

American Indian and Alaska Native adolescents

have the highest rates of motor-vehicle-related

accidental deaths. Motor vehicle deaths and injuries

among adolescents are associated with driving at

night and with drinking. Adolescent drivers do only

20 percent of their driving at night, but they suffer

166T0 m&e ~is Repofi more accmsib]e to the lay reader and for other reasons, OTA has chosen to U= ti term accidental in@Y in W5 Repofi. me

term preferred by those in the injury prevention community, however, is unintentional injury (e.g., 184). Those who prefer the term unintentional injury

believe that the term accidental injury implies that injuries cannot be prevented, whereas the term unintentional injury implies that while an individual

may not have consciously intended to hurt him or herself, some action taken or not taken may have prevented the injuxy. Perhaps to overstate this

perspective somewhat, all injuries are thus avoidable. The position that true ‘accidents’ do not occur (i.e., by chance, entirely witbout cause) correctly

brings attention to injuries as a public health problem to which additional preventive interventions can and should be applied, but it seems to be

unprovable. Use of the term “unintentional’ also may have the unfortunate effect of placing the onus of causation (and responsibility for precautions)

exclusively on the person who is injured, atthough in fact unintentional injuries may be caused, although unintentionally, by persons, organizations, or

systems other than the victim.

l~TFor exmp]e, available data on vis;ts to physicians’ oftlces and hospitals do not record the cause of inJ~.
Summary and Policy Options ● 1-89

more than half of their crash fatalities at night.

According to the National Highway Traffic Safety

Administration, about half of the motor vehicle

crash fatalities among adolescents are related to

alcohol, and about one-quarter of fatally injured

drivers ages 15 to 19 are intoxicated, It appears to

take less alcohol to put an adolescent at risk for a

serious or fatal motor vehicle crash than it takes to

put an adult at such a risk.

Of the approaches to the prevention of accidental

injuries among adolescents, there appears to be some

consensus that automatic protection (e.g., airbags in

cars, helmets for football players, environmental

improvements such as better street design) is the

most effective strategy for injury protection, followed by laws and regulation when strictly enforced

(e.g., motorcycle and bicycle helmet laws, safety

belt laws, nighttime driver curfews for adolescents),

and, lastly, education and persuasion. Declines in

accidental motor vehicle injury deaths during the

1980s, for example, have been attributed to State

safety belt 1aws and the subsequent increased use of

safety belts, and State minimum drinking age laws

(158). 168 However, programs combining education

and incentives (e.g., distribution of free or discounted bicycle helmets in conjunction with a

community-wide education program to encourage

use of helmets) have also shown some evidence of

effectiveness. Basic improvements in injury prevention strategies, such as additional driving time in

driver education classes or with parents prior to

licensing of adolescent drivers, enhanced access to

swimming lessons for poor adolescents, changes in

sports regulations, and preventing inappropriate

access to firearms, also seem warranted.

Efforts to develop a national strategy to prevent

accidental injuries among adolescents have been

hampered in part by a lack of information on both the

causes of many such injuries and on the effectiveness of interventions to prevent accidental injuries or

limit their severity. Cultural, political, and economic

factors also appear to have impeded the adoption of

preventive strategies that are likely to prove effective (see, e.g., 25). For example, there is no Federal

regulation mandating the installation of airbags in

Table 12—Specific Options Related to Accidental

Injuries (ch. 5)a

Option 2: Support Federal data collection and research.

Data collection:

● Support the collection of national data on accidental injuries

and their causes from the spectrum of health services

delivery settings (including clinics, emergency facilities, and

schools). Data collection should include the measurement of

exposure as a risk factor.

Research:

Support research to investigate more fully the causes of

injuries and injury related deaths, including research on

accidental injuries and deaths (particularly motor vehicle

deaths, drowning deaths, firearm-related deaths, and sportsrelated injuries).

Support research and rigorously evaluated demonstration

projects on innovative ways to prevent accidental injuries

(e.g,r communitywide education and incentives to increase

the use of bicycle helmets, efforts to provide more driving

time in school-based driver education classes).

Support research on the special needs of adolescents

coming to emergency facilities as a result of accidents.

Option 3: Foster changes in adolescents’ environments.

● Mandate the use of airbags in cars and trucks, including the

older cars and trucks that are likely to be used by adolescents.

. Mandate the use of bicycle and motorcycle helmets.

● Support local lending programs to distribute free protective

equipment (e.g., football and bicycle helmets) to adolescents

in economic need, similar to programs that lend automobile

infant seats to needy families.

~ptions related to intentional injuries (e.g., suiade and homicide) are

presented in other tables. Options related to suicide are in table 18,

“Speeific Options Related to Mental Health Problems, ” and options

related to homidde are in table 20, “Speeific Options Related to

Delinquency. ”

SOURCE: Office of Technology Assessment, 1991.

cars and trucks; gun control remains a controversial

issue

169 ; increased driving time in school driver

education classes and additional certified trainers for

school sports would cost schools money; and bicycle

helmets are expensive,

Specific options related to prevention and services related to accidental injuries among U.S.

adolescents are presented in table 12.

Chronic Physical Illnesses (ch. 6)170

Many adolescents experience acute respiratory

illnesses or other transient health problems, but a

few adolescents experience chronic physical illnesses or disabilities. Good recent clinical epidemiological data specific to U.S. adolescents’ physical

1680TA dld ~ot evaluate the ~alldity of fic~c attributions, me cause of d~lines in deaths by droting, which have been more marked th~ de~]ineS

in motor vehicle-related death (65), is not known

l~gAs noted emlier, however, the sale of firearms to adolescents is illegal (See Ch. 13, ‘‘Delinquency: Prevention and Services, ’ in Vol. II).

1 l~ls chapter excludes ~~ ~hyslcal he~~ p~blems of AIDS and o~er S’rDS, which were felt 10 merit discussion ill a Separate chapter (See ~h. ~,

‘ ‘AIDS and Other Sexually Transmitted Diseases: Prevention and Services, ” in Vol. 11).
I-90 ● Adolescent Health-Volume I

health are not available, but the best estimates

suggest that 5 to 10 percent of adolescents experience a serious chronic condition that severely limits

their activities (78, 291). These include leukemia,

severe asthma, cystic fibrosis, traumatic brain injury, cerebral palsy, diabetes, hearing or visual

impairment, sickle cell disease, or mental retardation.

The last national survey of the physical health of

adolescents that actually involved clinical examinations of large numbers of adolescents was completed

in 1970; data from that survey suggested that 22

percent of adolescents had some significant physical

problem that could interfere with their development. 171

Information is particularly limited on the physical

(and other) health problems of poor and racial and

ethnic minority adolescents and on health problems

from the perspective of adolescents. There are

virtually no reliable data on the health status of

minority and poor adolescents and their utilization

of health services. Data comparing the health

concerns of adolescents, their parents, and health

care providers suggests that adolescents have concerns that differ substantially from those of health

care providers and that, even in relation to clinical

findings of health care providers, parents may

minimize the health problems of adolescents. Yet

national health survey information, especially for

younger adolescents (e.g., those under age 17) is

routinely collected from parents, rather than from

the adolescents themselves.

Specific options related to chronic physical illnesses are presented in table 13.

Nutrition and Fitness Problems (ch. 7)

Adolescent-specific data on nutrition and fitness,

aside from average nutrient intake information, are

limited and often neglected in favor of data on

adults. Existing data represent the average adolescent population, often missing the smaller minority

and ethnic groups. In addition, research on nutrition

and on fitness is hampered by inconsistent outcome

measures and other methodological problems. A

major problem is the absence of research on how

Photo credit: Benjamin Smith, Washington, DC

Information is particularly limited on the physical (and

other) health problems of poor and racial and ethnic

minority adolescents and on health problems from the

perspective of adolescents.

adolescents’ nutritional and fitness behaviors affect

their current or future health.

If one accepts the conventional wisdom concerning nutrition and fitness needs, 172 available data

suggest that most adolescents suffer from some

nutritional or fitness problem (usually mineral

deficiencies, imbalance diets, and overweight or

obesity). Female adolescents and those adolescents

who are most intensively engaged in fitness and

athletic activities are more likely than others to have

nutritional problems, Available information suggests problems with obesity for black female adolescents, Mexican Americans, Native Hawaiians, American Indians and Alaska Natives, Samoans, and

Tongans of both sexes.

171A Natio~ He~~ and Nu~tion Examination Smwey (NHANES III) will be completed in 1994 (See ch. 6, ‘‘Chronic Physical Illnesses: Prevention

and Semices. ‘‘ in Vol. II). Children as a group, but not adolescents speeiflcally, are being oversampled for this survey. Ordy 3,220 adolescents ages 12

to 19 are included in the survey, while approximately 11,000 indlviduaJs ages 2 months to 11 years are included (7,771 of whom are younger than 6).

The numbers of 10- and I l-year-olds are not available separately.

ITz~t is, one ~sumes mat tie same nutrition and fitness factors that adversely affect adult health adversely affect adolescent healti.
Summary and Policy Options . I-91

Table 13—Specific Options Related to Chronic

Physical Illnesses (ch. 6)

Option 1: Improve adolescents’ access to health and related

services.

. Support efforts to reduce fragmentation in delivery of health

services to adolescents with chronic physical illnesses.

. Provide financial support to families of adolescents with

catastrophic health care needs.

• In health education, support efforts to inform adolescents

about the availability of treatments for problems of importance to them (e.g., acne, dysmenorrhea).

Option 2: Support Federal data collection and research.

Data collection:

● Support the collection of information on the prevalence of a

broad range of physical health problems, including serious

chronic problems of low prevalence and chronic problems of

importance to adolescents.

. Support oversampling of minority, poor, and rural adolescents in population-based and health services utilization

surveys.

Research:

● Support efforts to determine from adolescents themselves

the types of health problems that are of importance to them.

. Study financing alternatives for adolescents with catastrophic health care needs.

SOURCE: Office of Technology Assessment, 1991.

Photo credit: Benjamin Smith, Washington, DC

A major shortcoming in nutrition and fitness research is the

absence of information about how adolescents’ nutritional

and fitness behaviors affect their current or

future health.

Adolescents appear to have little information

about nutrition (including information on how to

interpret nutrition information on food labels), and

there is little evidence that current school-based

nutrition education efforts, with the possible exception of those that take adolescents’ preferences into

account, influence what adolescents eat. Others,

such as the family, community, or school, may have

more control than adolescents over their nutritional

choices.

Photo credit: Coray Macklin, Atianta, GA

Adolescents’ physical abilities change over time and are

highly individual.

Adolescents’ physical abilities change over time,

and may be highly individual, depending on such

factors as gender, race, the rate of physical development and growth, and specific health problems. It is

not clear that those involved in overseeing the

physical education of adolescents are aware of these

individual and developmental differences, or that

they take them into account in designing physical

education activities. Access to fitness activities is a

special problem for many adolescents with chronic

physical and mental illness and disabilities.

Specific options related to adolescents’ nutrition

and fitness problems are presented in table 14.

Dental and Oral Health Problems (ch. 8)

The prevalence of caries increases during adolescence, but national data show a remarkable decline

in the prevalence of dental caries among U.S.

adolescents who are in school. National data on the

dental and oral health of adolescents not in school,

disabled adolescents, adolescents in institutions,

minority adolescents, and poor adolescents are

generally not available.

The fluoridation of water supplies in the United

States, initiated in 1945 with the support of the

Federal Government, is believed to be largeIy

responsible for recent declines in dental caries

among U.S. children and adolescents. As of 1988,

fluoridated tap water was available to 61 percent of

the United States population (276). One alternative

to fluoridated tap water is the topical application of

fluoride to the teeth during a visit to the dentist.
I-92 ● Adolescent Health-Volume/

Table 14—Specific Options Related to Nutrition and

Fitness Problems (ch. 7)

Option 2: Support Federal data collection and research.

Data collection:

● Support a survey of schools and communities to determine

the availability y of facilities for a range of physical activities

and the competence of adults supervising physical education.

. Support the routine collection of data on adolescents’

nutritional status with oversamplings of disabled, minority,

and poor adolescents in population-based surveys.

Research:

● Support research on the effects of adolescents’ nutrition and

fitness choices on adolescents’ current and future health.

• Support research on the nutritional and fitness preferences

of adolescents in order to help target educational and other

preventive interventions.

. Support research on the relationships between nutritional

needs and varying levels of physical activity.

Option 3: Foster changes in adolescents’ environments.

● Support the provision of healthy nutritional choices to

adolescents in schools and the community (e.g., in fast food

outlets),

. Support efforts to improve access to fitness activities for

adolescents with special health care needs (e.g., the chronically ill and disabled), overweight, and poor adolescents.

. Support the education of physical education teachers,

coaches, trainers and others about adolescent-specific

factors that could influence adolescents’ physical abilities.

SOURCE: Office of Technology Assessment, 1991.

It is important that adolescents have regular visits

to the dentist so that they can receive preventive

dental services (e.g., cleaning, education about

personal dental hygiene) and therapeutic services

(e.g., filling of dental caries, treatment of rampant

caries, treatment of severe malocclusion). Currently,

the dental visit is the primary locus for dental and

oral health education, suggesting that limited access

to such visits may interfere with appropriate dental

health education.

Two factors that greatly influence adolescents’

access to basic and other dental care are income level

and the possession of health insurance that covers

basic dental services. Adolescents from low-income

families who do not have Medicaid are the least

likely to have private dental insurance and are also

the least likely to make annual dental visits, followed by adolescents on Medicaid, and privately

insured adolescents. Most privately insured adolescents do not have basic dental benefits.173 Dental

programs in public health clinics may not provide

Table 15-Specific Options Related to Dental and

Oral Health Problems (ch. 8)

Option 1: Improve adolescents’ access to health and related

services.

● Support Medicaid reforms (e.g., increase reimbursement

rates, standardize some administrative procedures, enforcement of current Federal Medicaid requirements for State

participation) to encourage more dentists to participate in the

program.

. Support efforts to ensure that publicly funded dental programs offer adolescents basic preventive and therapeutic

services (e.g., topical fluoride, sealants, prophylaxis, restorations, and space maintenance).

Health education:

● Support the provision of information to adolescents on dental

hygiene and means of access to services.

. Support education of dentists on adolescent-spedfic conditions and needs (e.g., localized juvenile periodontitis and the

effects on oral health of certain behaviors such as the use of

smokeless tobacco).

Option 2: Support Federal data collection and research.

Data collection:

● Support the collection of dental health information on

adolescents who are not in school, disabled, in institutions,

racial and ethnic minorities, and poor.

● Support research on the availabilit y of dental care for poor

and low-income adolescents not eligible for Medicaid.

Research:

● Support research on the immediate and long-term physical

(e.g., nutritional) and psychological (e.g., self-esteem, social

withdrawal) health effects of poor adolescent dental and oral

health.

Option 3: Foster changes in adolescents’ environments.

. Support efforts to improve access to fluoridated water.

SOURCE: Office of Technology Assessment, 1991.

certain basic dental services that could reduce or

prevent adolescents’ dental and oral health problems

(237).

Information on adolescents’ attitudes or behaviors related to dental or oral health and information

on the effectiveness of educational interventions in

promoting dental and oral health is generally lacking.

Specific options related to adolescents’ dental and

oral health problems are presented in table 15,

AIDS and Other174 Sexually Transmitted Diseases

(ch. 9)

In recent years, there has been growing national

alarm about and attention to the problem of AIDS,

a fatal disease caused by HIV. Currently, the

prevalence of AIDS among U.S. adolescents is not

li’3see ~h. 16, 1‘Fin~ci~ &ess to H~~ services, ’ in vol. ~.

174A] ~ough HIV, he VirUS that cau%s AIDS, can be, and usually is, transmitted sexually in adolescents, there are other modes of tianstissiow such

as through intravenous drug use and through the transfusion of contaminated blood and blood products, that are not common to many other STDS although

they may occur.
Summary and Policy Options ● 1-93

very high. As of September 1990, there were 568

cases reported among 13- to 19-year-olds (280). This

situation should not be interpreted as eliminating

cause for concern, however, because the prevalence

of HIV infection is undoubtedly higher, The median

interval between infection with HIV and the development of AIDS is about 10 years (278), so one

would not expect many adolescents to have fullblown AIDS.

In the absence of a cure for AIDS, preventing the

spread of HIV among adolescents is essential. One

way of preventing the spread of AIDS is to

encourage adolescents to delay the initiation of

sexual intercourse or prevent intravenous drug use.

For adolescents who are sexually active, ’75 the use

of condoms is essential. Recent data suggest an

encouraging increase in adolescents’ use of condoms, but more than half of sexually active female

adolescents do not use condoms at first intercourse

(68) and only 22 percent of sexually active females

reported current176 use of condoms in 1988 (141).

More creative and effective approaches are needed

to prevent the spread of HIV infection, AIDS, and

STDs among adolescents who are not yet infected.

Apart from ensuring the safety of the Nation’s blood

supply, efforts to prevent the spread of HIV infection

include encouraging adolescents (especially young

adolescents) to delay the initiation of sexual activity,

encouraging sexually active adolescents to use

condoms and ‘‘safer sex practices, ’ and encouraging adolescents to refrain from intravenous drug use

or sharing contaminated needles. For many reasons,

including time and fiscal restraints, few careful

evaluations of AIDS and STD prevention projects

have been conducted. AIDS prevention efforts, it

often seems, do not seem to take advantage of the

opportunity to encourage the simultaneous prevention of other STDs. Efforts to prevent AIDS and

other STDs are generally impeded by a lack of

information about adolescents’ attitudes and sexual

practices and a seeming unwillingness on the part of

program developers and policymakers to act on

information that is available.

Controlling the spread of HIV infection and STDs

also means identifying adolescents who have these

Photo cm&t: Centro del Control de /as Enfermedades

de Ios Estados Unitos

The link between the prevention of AIDS and the

prevention of other sexually transmitted diseases (STDs) is

often not made in health education efforts.

conditions and providing effective treatment (if

available) and counseling about safer sex practices,

Possibly, information about the availability of confidential treatment could be communicated to adolescents through health education courses offered in

schools. It is more difficult to inform adolescents

who are not in school.

Adolescents’ compliance with treatment regimens for STDs have been shown to be more

effective when they are delivered by clinicians who

are responsive to adolescents and their health

problems and who are perceived by adolescents to be

friendly, understanding, and willing to take their

time; and when treatment is administered in singledose regimens (if available) (1 1,16,122).

175k 1988, 4Z,5 percen[ of 15- to 1 g-year-old females surveyed forthe DIIHS National Survey of Family Growth reported havi%had sexu~ intercourse

in the last 3 months (68), Certain adolescents (e.g., male adolescents, black adolescents, adolescents living on the streets) are more likely to be sexually

active than others.

IT~Es(~t~ of tie L ‘Cment’ use of condoms are based on responses to a question to female adolescents participating in the DHHS National Survey

of Family Growth about what form of conhaception they are using now (141).
I-94 ● Adolescent Health-Volume I

Photo credit: Education Week

Congress could support the provision to adolescents of

information relevant to obtaining access to services for the

prevention and treatment of HIV infection, AIDS,

and other STDs.

Treatments for HIV infection and AIDS (e.g.,

zidovudine) are undergoing clinical trials. Access to

clinical trials of AIDS treatments is difficult for

adolescents with AIDS or HIV infection who do not

have access to the mainstream health care delivery

system (e.g., homeless and runaway adolescents,

uninsured adolescents). No specific outreach is in

place to bring more of these adolescents into

research trials.

Specific options related to AIDS/HIV infection

and STDs among adolescents are present

16.

Pregnancy and Parenting (ch. 10)

ed in table

The United States has higher adolescent pregnancy rates, birth, and abortion rates than a number

of other industrialized countries 177 (see figure 14). It

has been estimated that 4 out of 10 U.S. females

experience pregnancy before the age of20(210), and

in 1988, there were nearly half a million births

(488,941 births) to U.S. females under age 20 (294).

About 65 percent (322,406 births) of these births

were out-of-wedlock (312,499 to females ages 15 to

19 and 9,907 to females under age 15) (210,294).

Adolescent mothers and their infants are typically in

need of substantial social support, including food,

income support, housing, mentoring, education,

vocational training, parenting skills classes, child

care, and employment.

Table 16-Specific Options Related to AIDS/HIV

Infection and Other Sexually Transmitted

Diseases (ch. 9)

Option 1: Improve adolescents’ access to health and related

services.

●

●

●

•

Encourage school districts to make condoms and condomrelated education easily available to the adolescents who are

most likely to be sexually active (e.g., older adolescents).

Support active and flexible approaches to the provision of

treatment for STDs to encourage adolescents to seek

treatment and return for followup care.

Target AIDS/HIV prevention (e.g., condom distribution) and

education efforts to adolescents Iiving on their own.

Support outreach efforts to bring adolescents who are not in

contact with the mainstream health care system into clinical

trials for AIDS drugs.

Health education:

● Support the provision of information to adolescents on the

prevention and treatment of AIDS and STDs.

● Support the provision to adolescents of information relevant

to obtaining access to services for the prevention and

treatment of AIDS and STDs.

● Support training and dissemination of information on the

specific needs of adolescents for health care workers in STD

clinics.

● Support the dissemination of prevention and education

efforts into nonmetropolitan areas, to younger adolescents,

to adolescents who are intravenous drug users, and homosexual or bisexual adolescents.

Option 2: Support Federal data collection and research.

Data collection:

● Mandate confidential reporting of a broader spectrum of

STDs.

● Encourage States to collect and report additional demographic data on those with STDs (e.g., smaller age breaks,

socioeconomic status, and race and ethnicity).

● Support the regular collection of population-based information on STDs, including HIV, among adolescents.

Research:

. Support research to assess the need for adolescent-specific

guidelines for the treatment of STDs and AIDS. Support

research into therapeutic regimens that are likely to increase

adolescent compliance (e.g., single-dose regimens).

SOURCE: Office of Technology Assessment, 1991.

Since the 1970s, sexual activity rates (the number

of individuals per 1,000 who have ever had sexual

intercourse) among U.S. adolescent females have

increased (see figure 15). U.S. adolescent pregnancy

rates have also increased since the 1970s, but the

increase in pregnancy rates has been modest in

comparison to increases in sexual activity rates

(from 94 pregnancies per 1,000 females under age 20

in 1972 to 109 in 1987) (figure 15). Pregnancy rates

among sexually active females declined between

1970 and 1985, suggesting that sexually active

adolescents were making more effective use of

contraception. More recent (1987) data suggest an

ITTOTA did not assess whether levels of sexual activity were equivalent across these natiom.
Summary and Policy Options . 1-95

Figure 14—Birth Rates, Abortion Rates, Miscarriage Rates, and Pregnancy Rates

Among Females Ages 15 to 19 in 11 Countries, 1983 - -

N umber/1,000 women

120

100

80

60

40

20

0

100.9

1

14. 7

43. 5

45. 4

Ii

6 . 4

14. 2

24. 8

79.3

F

12.1

13.5

Pregnancy rate ●

_ Birth rate

53. 4

F

7.4

34. 0

18. 6

‘1 1 ——. 4-.2

Birth rate 4 abortion rate + miscarriage rate

~ Abortion rate [ ] Miscarriage rate

93.3

13.4

—. -—-.

25.7

N

52. 8

[

7 . 7

. . . . . -

37. 4

12. 7

4 . 8

16. 8

15.71

45.8

6

. . . . . . . .

20.2

33.2

: 4.1 1

1----1 17.4

u-s. Canada Czecho - Denmark England Finland Hungary Nether- -. New Norway Sweden

slovak i a & Wales lands Zealand

Countries

SOURCE: National Collaboration for Youth, Making the Grade:A Report Card on American Youth (Washington, DC:

1989).

Photo credit: Katherine Criss, New York, NY

Adolescent mothers and their children typically need substantial social support.
I-96 ● Adolescent Health—volume I

Figure 15—Trends in Sexual Experience Rates and

Pregnancy Rates Among U.S. Females Ages 15 to 19

and Trends in Pregnancy Rates Among Sexually

Experienced U.S. Females Ages 15 to 19, 1970-88

Number/1,000 females

600 T—– –- - -- -– —-- - —— -.

I

I

500

400

300

200

100

o +-– , , , , [ f–~-T–~——~- T

1970 1974 1978 1982 1985 1988

Year

❑ Number of females x Pregnancy rate O Pregnancy rate

ages 15 to 19 who among sexually among all

have ever had experienced females ages

sexual intercourse females ages 15 to 19

15 to 19

SOURCE: office of Technology Assessment, 1991, based on data from the

following sources: Pregnancy rates: National Academy of

Sciences, National Research Council, Commission on Behavioral and Social Sciences and Education, Committee on Child

Development Research and Public Policy, Panel on Adolescent

Pregnancy and Childbearing, Risking the Future: Adolescent

Sexuality, Pregnancy, and Chidbearing, Volume II: Working

Papers and Statistic/ Appendixes, S.L. Ho Hofferth and C.D.

Hayes (eds.) (Washington, DC: National Academy Press,

1987); and J. Lipsett, Public Information Press Assistant,

Department of Communications and Development, Alan Guttmacher Institute, New York, NY, personal communication, Feb. 27,

1991. Sexual experience rates: J.D. Forrest and S. Singh,

“The Sexual and Reproductive Behavior of American %men,

1982-1 988,” Farni/yP/arming Perspectives22( 5):206-21 4, 1990;

and S.K. Henshaw, Alan Guttmacher Institute, New York, NY,

personal ~mmunication, May 21, 1990.

increase in pregnancies among sexually active

adolescent females, however (figure 15).

For largely unknown reasons, most available

contraceptives have not proven to be as effective

with adolescents as they are with older females. The

recent introduction of Norplant, an implantable

long-term contraceptive, has not been tested with

adolescents.

Photo credit: Education Week

There is little systematic knowledge about risk factors for

adolescents’ involvement in sexual activity, use of

contraceptives, pregnancy, abortion, and parenthood.

Congress could support research on factors that lead

adolescents to engage in unprotected sexual intercourse

and research on contraceptives.

Unfortunately, there is little systematic knowledge about risk factors for adolescents’ involvement

in sexual activity, use of contraception, pregnancy,

abortion, and parenthood. This lack of knowledge

limits the appropriate design of pregnancy prevention programs. Further, development of appropriate

designs is limited because most education-based

programs designed to prevent adolescent pregnancy

have not been rigorously evaluated.

Some interventions for pregnancy prevention

appear particularly promising and deserving of

implementation accompanied by rigorous evaluation. These include preventive education begun

before adolescents have begun to engage in sexual

intercourse, and broad-based programs that go

beyond education about sexuality (e.g., life-options

interventions 178) (23,145,169). Some broad-based

17sL~e-optiom ~temation5 d~i~~ to prevent adolescent pregnancy have provided work opportunities to develop jobrelated skills idODg Wih

educational training, family life educatio~ and discussion of sexuality.
.

Summary and Policy Options . /-97

programs achieve worthwhile goals other than

reductions in pregnancy rates (e.g., reductions in

school absenteeism), even if they are not able to

demonstrate a reduction in pregnancy rates (23,145,

169).

Most adolescent pregnancy prevention programs

focus on adolescent females. Given that males have

a role in pregnancy prevention (as well as in safer sex

practices to reduce the risk of HIV infection), there

is a compelling need to develop effective ways to

engage adolescent and young adult males in efforts

to prevent adolescent pregnancy.

Considerable research suggests the need for, and

effectiveness of, a range of intensive health and

other services for adolescents who become pregnant.

Promising approaches to preventing the potentially

adverse effects of an unwanted pregnancy include

improving access to pregnancy testing and counseling; improving the availability of abortion; and

improving the availability of adoption supports. For

adolescents who want to keep their babies, prenatal

and postnatal health care, and the provision of

housing, mentoring, education, child care, and

employment to pregnant and parenting adolescents,

are needed.

Not all adolescents who become pregnant and

want to bear their children may be able to obtain

adequate prenatal care. Among adolescents without

health insurance, the problem is particularly critical.

Even unmarried adolescent females whose parents

have otherwise adequate health insurance may not

be able to obtain prenatal care because of a loophole

in the Pregnancy Discrimination Act of 1978 that

omitted minor dependents from requirements for

coverage for prenatal care.

Studies of programs that have attempted to

arrange a comprehensive range of services (e.g.,

housing, child care, transportation, education, jobs)

for adolescent parents have found that problems

occur in attempting to locate and broker services.

Specific options related to pregnancy and parenting among adolescents are presented in table 17.

Mental Health Problems (ch. 11)

Although a national systematic epidemiologic

study of mental health problems among children and

adolescents has not yet been fully mounted, recent

data suggest that approximately 1 out of 5 adolescents ages 10 to 18 suffer from a diagnosable mental

disorder (e.g., conduct disorder, separation anxiety

disorder, depression). The identification of adolescents in need of mental health treatment by standard

assessment techniques is often based more on

adolescents’ outward behavior of concern to teachers, parents, and society at large than on adolescents’

subjective distress (e.g., depression and anxiety) and

the subjectively perceived needs of the adolescents

themselves. When asked, an average of one out of

four adolescents report symptoms of emotional

distress, although the rate is higher among rural and

Native American adolescents.

Certainly one of the most severe manifestations of

subjective distress among U.S. adolescents is suicide. In recent years, the U.S. adolescent suicide rate

appears to have increased; suicide is currently a

major cause of death among U.S. adolescents (see

figure 4 in “Major Findings”). In 1988, the suicide

rate among 15- to 19-year-olds was 10.3 suicides per

100,000 population (see figure 4 in ‘‘Major Findings’ ‘)—apparently triple the rate in the mid1950s.

179 Firearms are the leading method for

committing suicide, accounting for half of all

successful suicides.

Adolescents who have made a previous suicide

attempt are at increased risk for suicide. Other risk

factors for adolescent suicide include being male;

being white or Native American; the presence of a

mental health or substance abuse problem; concern

about sexual identity; school problems; family

disruption and parental loss; loss of a close personal

relationship (i.e., boyfriend or girlfriend); and exposure to other adolescent suicides.

Trends in adolescent suicide attempts are not

available, but according to data from the 1987

National Adolescent Student Health Survey, one out

of seven adolescent 10th graders reported having

attempted suicide (10). Females are more likely to

report suicide attempts.

Mental health promotion is a term describing a

broad range of efforts that seek to foster a healthy

mental equilibrium and maintain emotional stability

(39, 63); most mental health promotion efforts can

l?qcomp~som of suicide rates across tie should be viewed cautiously, however, beeause reports of suicides could be influenced by pubhc afiention

or greater acceptability of recording suicide as a cause of death. Problems concerning the validity of suicide data are discussed in depth in ch. 11, ‘ ‘Mental

Health Problems: Prevention and Services, ’ in Vol. II,
I-98 ● Adolescent Health—Voiume I

Table 17-Specific Options Related to Pregnancy and Parenting (ch. 10)

Option 1: Improve adolescents’ access to health and related

services.

Services for pregnancy prevention:

● Support efforts to make contraception (and information about

using contraception effectively-also see Federal research

options) readily available to sexually active adolescents.

● Support the provision of comprehensive services (i.e.,

mental health, social, educational, vocational services) to

pregnant and parenting adolescents.

Services for adolescents who are pregnant:

● Support outreach to ensure that pregnant adolescents who

choose to give birth remain in school and obtain prenatal

care. Support a range of intensive services for pregnant

adolescents who choose to bear children (including prenatal

care, housing, nutritional support, education, counseling).

. Eliminate the loophole in the Pregnancy Discrimination Act of

1978, which currently does not require that dependents other

than spouses be covered for prenatal care (also see ch. 76).

● Support equal opportunity to abortion services, including a

greater range of alternatives to parental notification and

permission (also see ch. 17).

Services for adolescents who are parents:

● Support the availability of a range of intensive services for

adolescent parents and their children, and of adequate

assistance to manage adolescents’ access to such services;

such services include housing, food, transportation, child

care, academics, and parenting education and assistance.

Health education:

● Support the provision to adolescents of information relevant

to obtaining access to contraceptive and other services that

could protect them against pregnancy.

● Support pregnancy prevention education for young adolescents, before they are likely to become sexually active.

Support implementation (with accompanying rigorous evaluation) of broad-based, intensive programs such as life-

●

●

options training and work experience programs which are

combined with participatory discussions of responsible sexuality, and the provision of contraception. Such innovative

efforts would require more intensive, and perhaps different,

training of family life educators.

Support the implementation (with accompanying rigorous

evaluation) of parent-child communication groups with a

focus on sexuality.

Support targeting of pregnancy prevention education efforts

to black and poor adolescents.

Option 2: Support Federal data collection and research.

Data collection:

● Support routine collection of data on adolescent sexual

activity and birth-related outcomes.

. Support routine collection of data on sexual activity, pregnancies, and pregnancy outcomes among racial and ethnic

minority adolescents.

● Support routine collection of socioeconomic status data on

adolescents who are sexually active, become pregnant,

have abortions, and become parents.

Research:

●

●

●

●

●

SOURCE: Office of Technology Assessment, 1991.

be distinguished from efforts that attempt either to

prevent the occurrence of specific mental disorders

or to restore the effective functioning of an individual with a major mental illness. Selected mental

health promotion programs have demonstrated success in enhancing the coping skills of adolescents,

their ability to function empathetically in social

settings, and their academic performance, but few

such programs have been implemented.

Concerns about mental health promotion and

primary prevention interventions have arisen as

some suicide prevention interventions have had

unintended negative effects. Some observers have

criticized the state of the art in prevention, asserting

that primary prevention of mental disorders is not

possible in most instances, because knowledge of

causes and mechanisms of adolescent mental disorders is so limited (189). This criticism seems

intended more to generate support for early treatment intervention for adolescents who show early

signs of mental health problems than to suggest that

Support research on the factors that lead adolescents to

engage in unprotected sexual intercourse.

Support research on contraceptive technology, with an

emphasis on technology that is appropriate for and acceptable for adolescents.

Support efforts to determine how to incorporate adolescents’

views in the design and evaluations of prevention efforts.

Support research on why pregnant adolescents do not more

frequently choose adoption as an option.

Support research on why efforts to provide a comprehensive

range of services to adolescent parents through case

management and referral have found that brokering such

services is difficult.

some primary prevention and mental health promotion efforts may not be worthwhile.

Very few data are available on adolescents’

utilization of or access to mental health services, but

all evidence suggests that, although access has

apparently increased, it is still very limited. One

factor that affects adolescents’ financial access to

mental health treatment is the fact that Medicaid and

many private, employment-based health insurers

place limitations on reimbursement for mental

health services that they may not place on services

for physical problems. Such limitations include

limitations on the number of visits, lifetime days of

hospitalization, reimbursement levels, and the need

to have a diagnosable disorder. In 1986, only half of

adolescents’ outpatient visits in organized mental

health settings were covered by commercial health

insurance or Medicaid (271).

Roughly half of the States have statutes that allow

adolescents who meet certain requirements (e.g.,

minimum age of 16) to obtain outpatient and/or
Summary and Policy Options ● I-99

Photo credit: Sasha Bruce Youth Network, Inc. Washington, DC

A major limit to adolescents’ access to mental health

services is the requirement by insurers that a person

have a diagnosable mental disorder to be covered

for services.

inpatient mental health services without parental

consent. These statutes seem to reflect legislative

concerns that a parental consent requirement might

discourage some adolescents from seeking treatment

for mental health problems because of a reluctance

to reveal such problems to their parents. The statutes

vary with respect to parental notification provisions,

but the inpatient statutes are more likely to require

or permit parental notification than the outpatient

statutes.

Some people are concerned that increases in

admissions to private inpatient mental health treatment facilities are indicative of widespread misuse

of commitment to control troublesome minors (326).

As a concomitant of the parental consent requirement, parents have sometimes been allowed to make

a ‘‘voluntary commitment’ of a minor child to a

mental institution or facility regardless of the

minor’s desire or need for services. A few States

have addressed this problem by requiring both the

minor’s consent and a parent’s consent for such

treatment.

Although increases in inpatient mental health care

utilization are viewed by some as a sign of increasing accessibility of mental health treatment, such

increases continue to cause concern in the absence of

objective criteria for admission or rigorous evaluations demonstrating the effectiveness of such care.

Research is essential on the availability and

effectiveness of standard providers and settings such

as school guidance counselors, inpatient treatment

and residential treatment care, and promising innovative treatments and approaches such as homebased care, crisis intervention services, therapeutic

foster care, therapeutic group homes, transitional

living, partial hospitalization (day treatment), and

‘‘wraparound’ services.

For the most part, Federal engagement in child

and adolescent mental health initiatives has not been

strong or consistent, although there are continuing

changes that hold promise for improvement. These

include recent amendments to the State Comprehensive Mental Health Services Plan Act, recent requirements for studies related to the care of seriously

emotionally disturbed children under the provisions

of Public Law 94-142, and funding for the National

Plan for Research on Child and Adolescent Mental

Disorders. Support for clinical training has received

little attention.

Specific options related to adolescents’ mental

health problems are presented in table 18.

Alcohol, Tobacco, and Drug Abuse (ch. 12)

In recent years, a great deal of national attention,

concern, and effort has been centered on the problem

of illicit drug use in American society. National

survey data from adolescents (and adults (232, 263,

266)) suggest that considerable decline in the use of

illicit drugs has been achieved, at least as selfreported by high school seniors and adolescents

living in households (see figure 16). In addition,

available information suggests that experimentation, regular use, and possibly problem use, of

substances that are legally available to adults but not

to minors-i. e., alcohol and tobacco-are considerably more prevalent among adolescents than is the

use of illicit drugs (see figure 8 in ‘‘Major Findings’ ‘). This is not to deny the continuing impact of

illicit drugs (and involvement in the illicit drug

trade) on many adolescents, particularly those in

some localities and with some other problems (e.g.,

school dropouts, homeless and runaway adolescents, incarcerated adolescents) (e.g., figure 12 in

‘‘Major Findings’ ‘),

What causes adolescents to use and abuse alcohol,

tobacco, and illicit drugs? Experimentation? family

conflict? peer influences? adult modeling? advertising? Conclusions are difficult t. draw because of
1-100. Adolescent Health—Volume I

Table 18—Specific Options Related to Mental Health Problems (ch. 11)

Option 1: Improve adolescents’ access to health and related

— —

services..

●

●

●

●

●

Have Medicaid and commercial insurers make health insurance as available for mental health problems as it is for

“physical” problems.

Support funding and treatment delivery approaches (e.g.,

“wraparound funding”) by the Federal Government, States,

localities, and other entities that respond to individual mental

health treatment needs, rather than continuing to finance

services tied to specific delivery sites.

Support efforts to increase the availability of mental health

services for adolescents in accessible settings (e.g.,

schools), including services for adolescents who do not yet

have a diagnosable mental disorder.

Support efforts to improve access to mental health treatment

services for runaway and homeless, American Indian and

Alaska Native, black, and poor adolescents,

Assuming the development of strict criteria for admission and

guidelines for practice, increase Medicaid reimbursement

rates for psychiatric hospitalization; alternatively, mandate

private psychiatric hospitals’ participation in Medicaid.

Support the implementation by schools and other settings

(with accompanying rigorous evaluation) of mental health

promotion interventions.

Support the provision to adolescents of information about

when to seek, and how to gain access to, mental health

services.

Increase support for the provision of adolescent-specific

clinical training to a range of mental health providers.

Option 2: Support Federal data collection and research.

Data collection:

● Support the collection of data on the availability y of and

utilization of a broad range of mental health services likely to

be used by adolescents (e.g., in primary health care,

schools, juvenile justice, social services, and child welfare).

Research:

●

●

●

●

●

●

●

Support independent research on the appropriateness of

current diagnostic criteria for adolescent mental health

programs.

Support multisite research comparing the effectiveness of

different mental health treatment settings and approaches to

coordinating treatment (e.g., case management).

Support the development of admissions criteria for mental

health treatment, beginning with treatments in the most

restrictive environments.

Support further research on models of comprehensive

services for emotionally disturbed adolescents and their

families.

Support a research study on the capability of adolescents to

decide whether or not to accept mental health treatment.

Encourage the Agency for Health Care Policy and Research

(within DHHS) or a similar agency to develop practice

guidelines for psychiatric hospitalization of adolescents.

Provide sufficient support for the National Institute of Mental

Health (within DHHS) to implement its National Plan for

Research on Child and Adolescent Mental Disorders.

●

aAlso SW table 22, “S~ific @tions Relat~ to the Delivery of Primary and Comprehensive Health Serviees to Adolescents, ” table 23, “SptXifk options

Related to Problems in Adolescents’ Financial Access to Services,” and table 24, “Specific Options Related to Concerns About Consent and Confidentiality

in Adolescent Health Care Decisions. ”

SOURCE: Office of Technology Assessment, 1991.

methodological problems in the available research.

Much of the research has not distinguished among

substances and among levels of use in any meaningful way, and almost none of the research is longitudinal (i.e., research that follows individuals across

time). Some research suggests that problem use of

drugs and alcohol is likely to follow mental health

problems. Research on the short- and long-term

consequences of a range of levels of drug and

alcohol use is scarce.

Extensive financial and human resources are

being applied to preventing drug use among adolescents, although there is little information on the

effectiveness of these efforts. The strategies that

have been most successful in reducing, or at least

delaying, substance use include life-skills decisionmaking programs, peer-led programs, and, for lowincome adolescents, alternatives programs. l80 T h e

generally unremarkable results of primary prevention programs do not necessarily imply that the

efforts should be discontinued. Both the rigorously

evaluated and not-so-rigorously evaluated programs

may achieve other goals, such as improvements in

social competence. However, it may be important to

assess the impact of drug prevention programs in

terms of these other outcomes. Otherwise, the

programs may not be continued if they are found to

be ineffective for drug abuse prevention or if

resources are withdrawn from the war on drugs.

Concerns about the current substance abuse treatment system for adolescents include the lack of

objective, standardized criteria for admission; potentially inadequate trainin g and credentials for

substance abuse treatment personnel; reliance on the

addiction model; the absence of methodologically

rigorous evaluations of treatment; and lack of access

to early intervention.

Specific options related to alcohol, tobacco, and

drug abuse problems among adolescents are presented in table 19.

lsOA/ferna~veS ~rogram me pro-s that provide alternatives to life in the drug culture, such u recreation md SpOrtS pK@UILS md Oumad

bound-type camping efforts.
Summary and Policy Options .1-101

Photo credit: Office of Technology Assessment

Substance abuse treatment that works well with adults may

not be appropriate for adolescents.

Delinquency (ch. 13)

Existing data sources do not provide reliable and

valid information on the extent of adolescent involvement in illegal behavior. Arrest data and

victims’ reports show a leveling off since their peak

in the mid- 1970s in adolescent arrest rates for

serious violent offenses and a pronounced decline

for serious property offenses (see figure 17). Unfortunately, though, there are worrisome increases in

arrest rates for serious some specific violent offenses

among adolescents. Since 1965, adolescent arrest

rates for aggravated assault have shown a rather

steady increase, and arrests for murder and nonnegligent manslaughter have increased since 1984 (see

figure 18).

Another troubling trend is the narrowing gender

gap in arrest rates, from 11.4 (males):l (female) in

1965 to 7.5:1 in 1987 for serious violent offenses,

and 6.7: 1 to 3.6:1 over the same period for serious

property offenses (303). The significance of these

changes —whether they reflect an increase in serious

offenses among female adolescents, manifest changing social views that permit or encourage police to

Figure 16-Trends in Illicit Drug Use by High School

Seniors, 1975-89

Percent

100

T

-

.

80 1 I

k-”------ A -

60 — 65.4

=—.——-*.–_— I

5C:– - - --– -~5~1—~ -+60.6 ‘—

40 45.0 ‘-———— 5’W

30.7 ~7T2~46”3 ~

20 29-

q

o +–—--r–-.—T———4

1975 1980 1985 1989

Year

4 Used any illicit drug ‘+ Used any illicit drug

in the past month in the past year

+ - Ever used an illicit drug

SOURCE: U.S. Department of Health and Human Services, “1969 National

High School Senior Drug Abuse Survey,” HHS News, RP0689,

Feb. 13, 1990.

L

---

A

I

@G

[(hfo~e

ZONE

t

Photo credit: Office of Technology Assessment

The social environment is thought to be an important

influence on adolescents’ alcohol, tobacco, and

drug use.
1-102. Adolescent Health—Volume I

Table 19-Specific Options Related to Alcohol, Tobacco, and Drug Abuse (ch. 12)

Option 1: Improve adolescents’ access to health and related

Services..

● Support efforts to improve access to early intervention

(accompanied by rigorous evaluation) for adolescents who

believe themselves at risk of substance abuse.

. Support early intervention for mental health problems (with

rigorous evaluation to determine whether such intervention

can prevent subsequent problem use of alcohol, tobacco,

and illicit drugs).

. Encourage the Agency for Health Care Policy and Research

(within DHHS) or some similar agency to develop practice

guidelines and criteria for quality assessment for substance

abuse treatment and treatment facilities for adolescents.

. Support expansion of Medicaid access to substance abuse

treatment.

Health education:

. Support the provision to adolescents of information relevant

to obtaining access to a range of substance abuse treatment

options (from early intervention to inpatient treatment).

Option 2: Support Federal data collection and research.

Data collection:

● Expand support for Iocal and more detailed surveys of drug

and alcohol use and national surveys that oversample racial

and ethnic minorities and a range of adolescents in different

socioeconomic groups.

● Collect utilization data on the range of substance abuse

treatment alternatives likeiy to be used by adolescents.

● Support inclusion of family income data in national and local

surveys of drug use (e.g., through use of proxies such as

street address); oversample low income, racial and ethnic

minority adolescents.

Research:

●

●

●

●

●

Support research to develop effective substance abuse

prevention and early intervention efforts for additional highrisk adolescents (i.e., adolescents who work, adolescents

with disposable income, homeless and runaway adolescents).

Conduct research on the use of alternative (to self-report)

measures of substance use.

Support longitudinal research to enable the tracking of

precursors and short- and long-term consequences of

adolescent drug use.

Support research that distinguishes between substance

use, problem use, and abuse for adolescents and research

that distinguishes dearly among different substances.

Support research on development and evaluation of effective treatments for adolescents with substance abuse problems.

Option 3: Foster changes in adolescents’ environments.

. Support a range of changes in the social environment that

have been associated with lower rates of problem use of

alcohol, tobacco, and illicit drugs, and may have other

beneficial effects on adolescent health and well-being (e.g.,

reductions in parental drug use, higher levels of adult

supervision, less contact with drug-using peers, perceptions

of socially acceptable life options).

Wxj sw ta~e 22, ‘tsp~ific options Related to the Delivery of Primary and Comprehensive Health Serviees to Adolescents,” ta~e 23, “SpWifb OPtiOns

Related to Problems in Adolescents’ Finanual Access to Services.” and table 24. “Scmcific Odions Related to Concerns About Consent and Confidentiality

m Adolescent Health Care Decisions.”

SOURCE: Office of Technology Assessment, 1991.

arrest more female adolescent offenders, or result

from some other factor—is not known,

As in the case of accidental deaths and suicides,

firearms area leading factor in adolescent homicide.

Despite Federal legislation that prohibits the sale of

rifles and shotguns until age 18, and handguns until

age 21, almost 60 percent of adolescent offenders

who committed homicide in 1988 used a firearm,

compared to 53 percent in 1976 (302). In addition,

the proportion of homicides involving adolescent

victims has increased (see figure 4 in ‘‘Major

Findings").

181

Certain demographic characteristics-being in

the age group 15 to 17, being male, and having

access to an urban area-are more associated with

serious delinquency than others. The relationship of

race to delinquency is unclear. When one examines

black and white adolescents’ self-reports of serious

offenses (1 .5:1 in 1976 (58)), racial disparities are

much smaller then those typically reported based on

arrest statistics, where arrest rates for black adoles-

.

cents far outnumber those for whites (3: 1 in 1987

(300)). Furthermore, about half of black adolescents

live in poor or near-poor families, many of them in

urban areas typified by high rates of crime and

limited educational or employment opportunities;

and adolescents of low income and adolescents who

live in urban areas are more likely to commit serious

delinquent acts than other adolescents.

Early (preadolescent) involvement in socially

disapproved behaviors, a number of family factors

(e.g., lack of parental supervision), low intelligence

(particularly poor verbal ability), and associating

with delinquent peers have been identified as factors

increasing the risk of serious adolescent delinquency; however, these factors also characterize a

large proportion of adolescents who do not go on to

become serious chronic delinquents. Thus, more

comprehensive models that include individual, familial, and community factors, including community economic and social factors, and that are

sensitive to interactions between an individual’s age

18 IBecause of l~ltatlons in avtilable data, OTA was not able to assess the ages of those who murdered adolescents.
Summary and Policy Options . I-103

Figure 17—Trends in Arrest Rates for Serious

Property Offensesa and Serious Violent Offensesb 

. . by

Persons Under Age 18, 1965438

Arrests /100,000 population

1600

1400

1200

1000

800

600

400

200

0

65 69 73 77 81 85 88

Year

Serious Serious

. + property t violent

offenses a

o f fen ses b

a.sen’ous ~OpQ@ offenses are specified offenses against property (i.e.,

burglary, larceny-theft, motor vehicle theft, and arson).

bSerjou5 vio/ent offen5es are specified violent offenses a9~nst a Person

(i.e., murder and nonnegligent manslaughter, forcible rape, robbery, and

aggravated assault).

SOURCE: office of Technology Assessment, 1991, based on U.S. Department of Justice, Federal Bureau of Investigation, Age-Spedk

Arrest Rates md Race-Specific Arrest Rates for Selected

Offenses 1965-1988 (Washington, DC: April 1990).

and his or her risk, are needed to explain and predict

delinquency.

Despite incomplete knowledge about the causation of adolescent delinquency, some programs

designed to prevent delinquency, while not widely

duplicated or tested, have shown promising results

in relatively rigorous studies. Overall, successful

approaches to prevention can be characterized as

those that have the following characteristics:

●

●

●

they are appropriately supportive of children

and adolescents and their families;

they are intensive (i.e., they involve the commitment of considerable time, personnel, and

effort); and

they are broad-based (i.e., they intervene in a

number of the systems (including family,

school, and peer) in which the child or adolescent is involved, and use multiple services (e.g.,

educational, health, and social) as appropriate

for the individual child or adolescent).

The most promising primary prevention efforts

appear to be conducted early in life for high-risk

children, such as the Perry Pre-School program and

a broad-based prevention intervention that included

parent-skill training. Promising secondary prevention approaches, conducted during adolescence after

antisocial behavior has become apparent, include the

intensive psychotherapeutic and education/job placement intervention evaluated by Shore and his

colleagues and the integration of identified antisocial adolescents into activities with nondisturbed

peers. These models deserve additional implementation accompanied by rigorous evaluation.

Also in need of attention as preventive factors are

limits on access to firearms and educational interventions intended to help adolescents avoid becoming victims. The role of firearms in delinquency has

not been well researched, but it is clear that the use

of guns can exacerbate the outcome of violent

delinquent and adult criminal acts.

There are conflicts inherent in the multiple goals

of the juvenile justice system: rehabilitation, punishment, deterrence, and public safety. In recent years,

society has apparently taken a more punitive approach to dealing with adolescents who commit

delinquent acts; however, increases in juveniles held

in public facilities have occurred only for nonwhites.

Nearly 40 percent of adolescents in State-operated

juvenile detention facilities are black; 15 percent are

Hispanic (see figure 19). Between 1985 and 1987,

the number of black and Hispanic juveniles increased 15 percent and 20 percent, respectively.

Almost nothing is known about the effectiveness

of the current juvenile justice system as it normally

operates in reducing subsequent delinquency among

adolescents. It is clear that health care for adolescents in juvenile confinement is a serious cause for

concern, in part because incarcerated adolescents

have a greater than average number of health

problems and in part because health problems often

increase during confinement. One oft-cited impediment to improving access to health services is the

Federal regulation that prohibits Medicaid payment

for health services provided within correctional

facilities. In addition, only 32 of the more than 3,000

eligible facilities have been accredited as meeting
I-104 ● Adolescent Health—Volume I

Figure 18-Trends in Arrest Rates for Aggravated Assaulta and Murder and Nonnegligent Manslaughterb — — by

Persons Age 18 and Under, 1965-88

500

400

300

200

100

0

Aggravated assault’

Arrests/100,000 population

I

30

65 68 71 74 77 80 83 86 88

25

20

15

10

5

Murder and nonnegligent manslaughter b

Arrests/100,000 population

0

65 68 71 74 77 80 83 86 88

Year Year

`~ Age 12 and under ~ Age 16 %+ Age 12 and under ~ Age 16

~- Ages 13 to 14 + Age 17 -+ Ages 13 to 14 +– Age 17

~ Age 15 ~ Age 1 8 ‘~ Age 15 ~ Age 18

aAggravat~a~~au/t is an “nl~ul attack by one ~r~on upon another for the purpose Of infl~ting severe or aggravated bodily injury. This type of assau[t

usually is accompanied by the use of a weapon or by means likely to produce death or great bodily harm.

b~u~erandnonnW/@nf ~m~/aWhterrefer t. the wil~ul (n~nqligent) tilling of one human being by another. Note that the ~le is different from that for

aggravated assault, in order to show the recent increases.

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Justice, Federal Bureau of Investigation, Age-Sped% Arrest Rates and

Race-Specific Arrest Rates for Sekwted@fenses 1$%5-1988 (Washington, DC: April 1990).

existing voluntary standards

care. 

182

for providing health analysis of Office of Juvenile Justice and Delinquency Prevention activities seems warranted.

Executive branch support for the lead Federal Adolescents and young adults (ages 11 to 24) are

the age group most likely to be the victims of theft, agency in juvenile justice and delinquency prevention, the Office of Juvenile Justice and Delinquency

rape, robbery and assault (see figure 9, in ‘‘Major

Findings’ ‘). These data suggest the need for educatPrevention in the U.S. Department of Justice, has

declined, and the agency currently provides little

ing adolescents about how to avoid becoming

victims, including becoming victims of actions by

support for prevention of delinquency. Some have other adolescents.

suggested that Federal efforts concerning delinquency be returned to the U.S. Department of Health Specific options related to delinquency problems

and Human Services. At the least, an in-depth among adolescents are presented in table 20.

IEZ1t is not bow how my of the no~mr~ited facilities either appfitxl for accreditation and were turned do~ or did not apply for accreditation.

In any event, standards remain strictly voluntary.
Summary and Policy Options . i-105

Figure 19--Distribution of Juveniles in Custody in

Public Juvenile Facilities by Racial and Ethnic Group,

1987a b

Black

(non-Hispanic)

3 9%

Hispanic

(black and white)

Other

\

/ 3%

/

White

(non-HisPanic )

4 4 %

aBased on sing[~ay census count (see ch. 13, “Delinquency: prevention

and Servi@s, ” in Vol. (I, for explanation), The total population in public

juvenile facilities on census day in 1987 was 53,503.

bpublic Juvenile facilities include institutional facilities and open facilities.

They also include short-term faalities and long-term facilities. According

to the Offce of Juvenile Justice and Delinquency Prevention, the vast

majority (91 percent) of adm issions to public juvenile facilities in 1987were

to institutional rather than open facilities; 67 percent of admissions to

public juvenile facilities were to long-term facilities and 33 percent were to

short-term facilities.

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Justice, Office of Justice Programs, Office of Juvenile

Justice and Delinquency Prevention, “Children in Custody:

Public Juvenile Facilities, 1987,” Juveni/e Justice Bu//etirr,

October 1988.

Hopelessness (ch. 14)

Hopelessness is one of the riskiest situations for

adolescents. In addition to behaviors and conditions

associated with hopelessness that may present a risk

to future health (e.g., engaging in survival sex183),

available evidence suggests that adolescents who are

homeless with their families or on their own (i.e.,

runaways and ‘‘ thrownaways "

1 8 4

) are likely to

already suffer disproportionately from health problems. Efforts to address the needs of substanceabusing parents, prevent child abuse, provide counseling for families about gay sexual orientations, and

provide supportive interventions for adolescents in

foster families and institutions may be appropriate

Photo credit: Office of Technolgy Assessment

The health care of adolescents in juvenile confinement is

a serious cause for concern, because adolescents in

confinement have a greater than average number of health

problems, because their health problems may increase

during confinement and because only 1 percent of eligible

juvenile justice facilities have been accredited as meeting

existing voluntary standards for providing health care.

strategies for preventing adolescents from running

away from home. Different approaches are needed to

prevent hopelessness among families with adolescents.

185

For those adolescents who are already homeless,

providing shelter is a necessary, but not sufficient,

intervention. Until recently, Federal programs to

serve the needs of homeless adolescents on their

own have been limited primarily to temporary

(2-week) shelter. Funds for the transitional living

programs authorized by Public Law 100-690 were

not appropriated until fiscal year 1990, and pro183C CSmlval ~x” is e%a~ in sexti intercourse in exchange for food, shelter, money, or ~gs.

1~ ‘Thrownawqs’ me adol~centswhohave been asked or told to leave home by parents or guardians. Runaways may also lave~w ~eYP~ive

that they are not wanted, in many cases apparently because they have been abused.

lssne Stewart B. Mctiey Homeless Assistance Act Amendments of 1990 (Public Law 1OI-645) provided for gfmts for demomtration Pmgr~

intended to prevent hopelessness among families with children (Subtitle F, Family Support Centers); $50 million for fiscal year 1991 and $55 million

for fiscal year 1992 was authorized for a total of 30 competitive grants.
1-106. Adolescent Health—Volume I

Table 20-Specific Options Related to Delinquency

(ch. 13)

Option 1: Improve adolescents’ access to health and related

services.

. Change Federal regulations so that adolescents in correctional facilities are eligible for Medicaid.

. Support the development of Federal quality standards for

health care in juvenile justice facilities and mandate that ail

juvenile justice facilities meet the standards.

Option 2: Support Federal data collection and research.

Data collection:

● Support the regular collection of self-report data on a range

of adolescent offenses for a range of ages.

● Support the collection of standardized data on adolescent

offenders’ social adjustment (e.g., recidivism) following their

release from juvenile facilities.

Research:

● Support research on appropriate evaluation methods for

delinquency prevention.

. Support evaluation research in delinquency prevention and

treatment.

● Support research on ways to prevent the commission of

violence by adolescents and the victimization of adolescents.

● Support research on effective rehabilitative treatment approaches to juvenile offenders in the community rather than

institutions.

● Support an objective examination of the placement, mission,

and accomplishments of the Office of Juvenile Justice and

Delinquency Prevention (currently in the U.S. Department of

Justice).

Option 3: Foster changes In adolescents’ environments.

. Support early intervention programs that provide comprehensive care to families.

SOURCE: Office of Technology Assessment, 1991.

grams were not initiated until October 1990. 186

Important service needs include access to education

and employment training, AIDS/HIV infection prevention and education, mental health counseling,

training in independent living, and other health

services.

Specific options related to hopelessness among

adolescents are presented in table 21.

.-

Photo credit: Sasha Bruce Youth Network, Inc., Washington, DC

Homeless adolescents have needs for interventions that

go beyond their need for shelter.

Major Issues Pertaining to the Delivery of

Primary and Comprehensive Health Services to

Adolescents (ch. 15)

Adolescents are relatively unlikely to use the

services of private office-based primary care physicians, having the lowest rate of use of any age group

(see figure 20). About one-quarter of adolescents’

visits to private office-based physicians are to

pediatricians, two-fifths are to general and family

practice physicians (35 percent) or internists187 ( 5

percent), and the rest are to specialists (287) (see

figure 21).

Given that adolescents clearly have health problems that would benefit from care, a number of

nonfinancial and nonlegal reasons 188 why adolescents might exhibit relatively low utilization of the

services of primary care physicians and, to some

lg6~ranS1tiona/ lik~ing pr~gra~ are StrUCWtZXI programs that provide shelter while helping young people develop the skills they need tO live On hek

own. For fiscal year 1990, $9.867 million was appropriated and $9.939 million for fiscal year 1991 in the form of grants (156). Grantees are required

to submit annual reports to DHHS on their activities and achievements and statistical summaries describing the number and characteristics of the

homeless youth served by the transitional living progmms (42 U.S.C. 5714-2). An evaluation is scheduled to begin in late 1991. Programs are limited

to adolescents and young adults between ages 16 and 21. The Young Americans Act described above, also allows for (but does not require) grants to

be made for transitional living services to young individuals who are homeless, with no age restriction specitled (Public Law 101-501, Title IX; 42 U.S.C.

12338).

lsT~nfern~~(~ me physici~ practictig in general internal medicine. Internal medicine in the United %Mes differs tim family pHiCtiCe ~lly ~ not

providing extensive training for pediatric and obstetric care and in providing more experience with severe and complex illness (324). Internal medicine

differs from the subspecialties that have developed out of internal medicine (e.g., cardiology, oncology, hematology) by offering primary care, including

first contact care and referrals to subspecialists when warranted (196, 324).

1l?RF1mcl~ issues in access ~e diwu~sed ~ Ch. 16, “Fiuc~ ~ess to Heal~ Senices, ‘‘ in Vol. III. In addition, the reasons for the relative lack

of physician interest in adolescent health care may be related to the relatively low level of financial remuneration associated with the intensive level of

cognitive services that are needed by adolescents (see “Barriers and Opportunities to Change, ” below).
Summary and Policy Options . I-107

Table 21-Specific Options Related to Hopelessness

(ch. 14)

Option 1: Improve adolescents’ access to health and related

services.

● Increase support for contraceptive, prenatal care, STD,

mental health, and substance abuse treatment, and legal

services intended to help adolescents who are homeless

alone or with their families.

. Continue to support, with appropriate evaluation, supervised

transitional living for homeless adolescents, with access to a

range of supportive services (health, education, employment, training).

. Support outreach efforts to help homeless and runaway

adolescents gain access to comprehensive health services.

Option 2: Support Federal data collection and research.

Data collection:

● Support systematic collection of data on the physical health,

mental health, and other needs of homeless and runaway

adolescents.

Research:

. Support rigorous research on what causes adolescents,

including white, middle-class, and gay adolescents, to run

away from their families.

Option 3: Foster changes in adolescents’ environments.

. Increase mental health support for families (e.g., family

counseling).

. Expand housing and income support for homeless families

with adolescents and for families with adolescents who are at

high risk of hopelessness.

SOURCE: Office of Technology Assessment, 1991,

extent, other health care providers, ’89 have been

examined. They include: the lack of availability and

willingness of physicians to treat adolescents; inconsistencies between adolescents’ perceived needs and

the care provided by physicians; adolescents’ concerns about confidentiality; and physicians’ and

other health care providers’ lack of competence to

identify and treat the health problems of adolescence.

Generally, however, there is little empiricaI research on the extent to which physicians and other

health care providers meet the needs of adolescents.

In some instances, the needs or desires of adolescents (e.g., for confidentiality of care, for certain

issues to be discussed during a health care visit) may

conflict with the requirements of laws pertaining to

the allocation of authority in health care decisionmaking, 190 with the needs of health care providers to

be paid, with the advisability of family (parental)

involvement in the health care experience, and with

overall societal perceptions of which health care

Figure 20-Visits to Private Office-Based Physicians

by U.S. Citizens, All Ages Combined and

U.S. Adolescents Ages 10 to 18, 1985

Visits/person

3 ] —

2.74

2.5

2

1.6

1

0.5

0

1.6 1.7

I

1.1

1

All ages All White

combined

Adolescents

Black ‘Other’

ages 10 to 18

SOURCE: Office of Technology Assessment, 1991, basedon U.S. Department of Health and Human Servims, Public Health Service,

Centers for Disease Control, National Center for Health Statistics, unpublished data from the 1985 National Ambulatory

Medical Care Survey, Hyattsville, MD, 1989.

Figure 21—Distribution of Visits to Private OfficeBased Physicians by U.S. Adolescents Ages 10 to 18,

by Physician Specialty, 1985a

Estimated number of

adolescents’ visits ~ 50,218,000

Orthopedic

surgery (7%)— All other specialties (7%)

11

-, 1

l!] ]]~k Dermatology (7%)

Pediatric

(23%) Ophthalmology (5%)

_ / ’

“~1 Internal medicine (5%)

/

Obstetrics and

gynecology (4%)

.\,,, General surgery (3%)

~~ Otorhinolaryngology (3%)

@’”psychiatry (2%)

General and family practice

(35%)

apercentage.s may not add to 100 because of rounding.

SOURCE: Office of Technology Assessment, 1991, based on U.S. Department of Health and Human Servkes, Pubiic Health Service,

Centers for Disease Control, National Center for Health Statistics, unpublished data from the 1985 Nationai Ambulatory

Medicxil Care Survey, Hyattsville, MD, 1989.

]~9M~st of the ~val[able rc~earch on ~dol=cent~’ “tll~ation patterns ~d exp~ences ~~h~th cue providers ~S foased on physicians as providers.

Further, most of the research on physicians has foeused on pediatricians as providers of adolescent health care.

l~sce ch, 17, “Co~~ent and confidentiality in Adolescent Health Care Decisionmaking, ’ in VO1. rn.
I-108 ● Adolescent Health—Volume I

Photo credit: Joe Sanders/American Aeademy of Pediatrics

Adolescents’ needs or desires for confidentiality of care

may conflict with laws pertaining to the allocation of

authority for health care decisionmaking.

problems are important. Nevertheless, available

evidence clearly suggests that the needs of adolescents—both those defined by adolescents and, to

some extent, defined by society-are not being met

by the contemporary mainstream primary health

care system.

The number of health care providers with both

interest and special skills in providing health care to

adolescents is not known, but available data suggest

that the number is quite small (perhaps 5,500).191

With the exception of the small group of specialists

in adolescent medicine, there is no group of health

care providers who are available, clearly defined as

appropriate, and clearly willing to provide care to

adolescents. For example, despite the potentially

increased importance of ‘‘anticipatory guidance’

during the adolescent years, pediatricians have been

found to spend an average of approximately 1

minute more with adolescents than they do with

other noninfant patients (90); one study suggests that

an average of 7 seconds a visit is spent on

anticipatory guidance (176). More rigorous (e.g.,

direct observational) studies and surveys of adolescents themselves finding that little time is spent

discussing the ‘‘new morbidities" issues that are

believed to be amenable to preventive educational

interventions or the health concerns of importance to

adolescents themselves (126,176).

Findings concerning physicians’ attitudes and

behavior with respect to confidentiality of care for

adolescents are both limited and variable, with 75

percent of members of The Society for Adolescent

Medicine and a random sample of pediatricians

expressing support for confidentiality for adolescent

patients (124), but a survey using a specific example

(a pregnant 15-year-old’s desire that her mother not

be told of the pregnancy) finding that the majority of

physicians would not abide by the patient’s request

for confidentiality (161).

The very small body of empirical work, much of

it methodologically limited, that has explored the

issue of health care provider competence in diagnosing and treating adolescents’ specific problems,

suggests the following:

●

●

●

●

●

primary care physicians appear to have difficulty in identifying children and adolescents

who have behavioral and emotional problems;

physicians as a group are currently not able to

identify substance abuse problems very effectively;

primary care physicians appear able to identify

acne in adolescent patients, but their ability to

treat acne has not been tested;

hospital services do not appear to adequately

document health problems in adolescent patients; and

physicians, nurses, social workers, psychologists, and nutritionists all consider themselves

relatively untrained in important areas of adolescent health (e.g., sexuality, handicaps, endocrine problems, contraception, psychosocial

concerns). 192

Almost no work has been conducted on the important issue of providers’ abilities to interact with

adolescents, regardless of the specific problems that

an adolescent may have. However, the studies that

have been conducted suggest that important characteristics include friendliness, understanding, and

willingness to take one’s time (11,122). One study

suggests that advanced training in adolescent health

care improves adolescent patient satisfaction (122).

1S’1OTA w= able t. ~~te that there are perhaps 2,CK)0 nonpsychiatrist physician specialists in adolescent medicine; 1,500 psycholo@@ wh ~ve

reported adolescents to be their primary professional interest; 1,500 members of the American Society for Adolescent Psychia~, and 370 members of

the North American Society for Pediatric and Adolescent Gynecology. In additioq health care providers that may be likely to treat adolescents and receive

some special training include family physicians, pediatric nurse-practitioners, nurse midwives, school nurses, health educators, and social workers.

However, none of these groups ascertain the extent of specialized professional interest in adolescents as opposed to otlm age groups.

lgzIssues re~t~ t. tie ~le of emergency personnel who come in contact with adolescents (e.g., those who have been in accidents, been ~m~ted, or

attempted suicide) are discussed in ch. 5, “Accidental Injuries: l%wention and Services, ” in Vol. II.
..—.

Summary and Policy Options . 1-109

Perhaps more disturbing than findings that many

health care providers are apparently not able to treat

adolescents, several studies have found that health

care providers have expressed relatively little interest in additional training. Further, except for those

who explicitly specialize in adolescent health care,

existing training requirements with respect to adolescents, while improving, are minimal. 193 Thus,

those adolescents who seek health care are likely

to see providers who have not been specially

trained to work with them. There is minimal

Federal support for clinical trainin g in adolescent

health and almost no systematic information on the

desirable features of training in adolescent health

care.

Given the apparent failure of both the primary

health care system and the specialty health care

systems to meet the health care needs of adolescents,

several innovations in health care delivery have been

attempted. These include the provision of comprehensive health (and, sometimes, related) services by

an interdisciplinary team of health care providers at

a single site (e.g., hospital-based adolescent health

care clinics, community-based adolescent health

care clinics, a teen center at an HMO, ‘ ‘free clinics, ’

multiservice centers, and, most extensively, schoollinked health centers), attempts to integrate services,

and efforts to involve adolescents in health services

planning and management.

Systematic evidence of the effectiveness of comprehensive programs in terms of improving health

outcomes is scarce. The only study to date that

compared special hospital-based adolescent health

clinics to hospital-based clinics without a special

adolescent focus found no outcome differences after

a year (54). However, the specially funded clinics

were more successful in getting adolescents to

disclose behavioral and lifestyle problems to their

clinical providers, and consequently to obtain care

for such problems (54). Reductions in school absenteeism, alcohol consumption, smoking, sexual activity, and pregnancy have been found in some schools

with on-site school-linked health centers, though not

consistently (105,339). In general, assessments of

the effectiveness of specialized comprehensive adolescent health care services (whether school-linked,

hospital-based, health maintenance organizationbased, or freestanding) have been few and methodologically limited. In addition, given the socially

embedded nature of many adolescent health problems, the capacity of any clinical program in and of

itself to completely alleviate the problems of adolescents may be limited.

What has often been found is that many of the

adolescents who use the services of school-linked

health centers are adolescents who have no other

source of health care,194 and that adolescents use

school-linked health centers for typicaI urgent care

for illness and injuries and for services otherwise

unavailable without high levels of income, generous

insurance policies, or breaches of confidentiality

(e.g., mentaI health counseling, reproductive health

care

195). Further, one of the few systematic studies

of school-linked health centers suggests that efforts

to meet the more intangible needs of adolescents

have been successful: the primary reasons cited by

students for using the school-linked health center in

their school were that users felt they could trust it

because it was part of the school; the school-linked

health center was easy to get to; and the staff was

caring (105). The number of repeat visits to schoollinked health centers is also cited as suggestive that

school-linked health centers are responsive to the

needs of adolescents as they perceive them (180).

When it comes to adolescents, then, school-linked

health centers and, perhaps to a lesser extent,

community- and health-care-organization-based adolescent health care centers, appear to respond to

many of the shortcomings of the traditional health

care system: Such centers attempt to provide comprehensive services that address the range of problems that many adolescents face (e.g., care for acute

physical illnesses; general medical examinations in

preparation for involvement in athletics; mental

health counseling; laboratory tests; reproductive

health care; family counseling; prescriptions; educational services; vocational training; legal assistance;

recreational opportunities; advocacy; coordination

193 For ~xmple, ~ ~~c~ed ~xp~ence ~ ~dol~mnt h~th ~~e a rqfied ~p~t Of ~ng for fi~e pdiarncti in J~uary 1990, tdthOU@

no patient age range nor duration of training was specifkd. Neither family practice nor internal medicine include specific curricula regarding adolescents.

194~~ fin~g is ~nfo~ded somew~t by the fact tit most school.l~ed he~~ c~te~ hve tin purposefully situated in COInmllXliti~ deemed

to be medically underserved.

]qsAppUenfly &cause they ~sh t. avoid delays ~ irnplmenting the broader range of semices tit me n~d most school-li~~ b~th centers do

not provide contraceptive methods on site.
I-110 ● Adolescent Health—Volume I

Photo credit: Katherine Criss, New York, NY

Comprehensive health centers for adolescents attempt to

provide services that address the range of problems many

adolescents face. Such services include care for acute

physical illnesses, general medical exams, reproductive

health care, mental health counseling, family counseling,

vocational training, recreational opportunity, and

child care services.

of care (e.g., with school personnel); advocacy%).

Settings are often designed with adolescents in

mind, to the extent possible. Adolescents are often

involved in the design and management of the

programs. In the case of school-linked health centers, the services are physically accessible, because

they are located in or near where most adolescents

spend much of their waking day.

However, there are certain ways in which schoollinked health centers and other specialized adolescent health care programs reflect some of the

limitations of the mainstream primary health care

system and can be strengthened.

For a variety of reasons, a reorganization of

adolescent health services to meet desirable criteria

for adolescent health services has not been realized.

The reasons are both formidable and interrelated.

They include community resistance to the provision

of contraceptive services and abortion counseling to

adolescents; resistance of organized medicine; resistance by schools to adding yet another responsibility

to the educational infrastructure; lack of a core of

adequately trained professionals to staff comprehensive programs; State Medicaid administrative barriers; lack of conclusive and convincing data on the

4!5

,/ --’ I

Photo credit: Bethesda-Chevy Chase Rescue Squad

Congress could support research aimed at evaluating, and

if necessary could support improvements in, training of

health care providers who work with adolescents.

effectiveness of such programs in reducing a number

of highly socially visible adolescent health problems; and, finally, lack of financing.

Major options related to the delivery of primary

and comprehensive health services were discussed

earlier in this chapter. Additional options are presented in table 22.

Problems in Adolescents’ Financial Access to

Health Services (ch. 16)

One out of seven adolescents, 4.6 million overall,

are without a key ingredient to access to health care:

health insurance coverage. This includes one out of

three poor adolescents who are not covered by the

Medicaid program, Adolescents in Southern states

are the most likely to be uninsured.

There is increasingly worrisome evidence that

escalating health insurance costs are threatening

coverage of adolescents and other dependents of the

working insured. Faced with rising costs of health

insurance, some families are choosing not to cover

their dependents. Some employers plan to cut

benefits for dependents, in particular mental health

and substance abuse treatment benefits.

I% Not all services are available at all centers.
Summary and Policy Options . I-111

Table 22—Specific Options Related to the Delivery

of Primary and Comprehensive Health Services to

Adolescents (ch. 15)

Option 1: Improve adolescents’ access to health and related

services.*

Option 2: Support Federal data collection and research.

Data collection:

● Support the collection of data on the Federal (within the

Bureau of Maternal and Child Health, Health Resources and

Services Administration, Public Health Service, U.S. Department of Health and Human Services) interdisciplinary training program in adolescent health care.

Research:

Support research aimed at improving adolescent-provider

interactions, including research on diverging perceptions of

adolescent health care needs.

Support research aimed at evaluating and, if necessary,

improving the content of training for adolescent heaith care

providers across a broad range of disciplines (medicine,

psychology, sociai work, health education, nursing).

Support research aimed at improving referrals among systems of care.

Support research on a range of alternative delivery mechanisms for adolescent health and reiated services.

Support research on the question of what “comprehensive”

and integrated means (and should mean) in the delivery of

health and related services for adolescents.

asee Major Option I related to improving adolescents’ access tO health and

related services that was presented in table 5.

SOURCE: Off Ice of Technology Assessment, 1991.

Even those adolescents with health insurance

coverage may not be eligible to receive the services

they most need. Most private health insurance plans

do not cover many of the important needs of

adolescents, including basic dental, hearing, vision,

and maternity-related benefits. Mental health and

substance abuse treatment benefits are universally

subject to separate and more stringent limitations

than for ‘‘physical’ problems. Preventive services

are generally not covered for adolescents unless they

belong to a health maintenance organization, 197

Little is known about the extent to which private

health insurance reimburses the nonphysician health

care professionals who could be critical to the

development of additional low-cost community

adolescent health care resources. Physician participation in Medicaid is particularly low among two

specialties of special importance to adolescents:

gynecologists and psychiatrists.

OTA finds that a combination of two proposals for

increasing coverage (an expansion in Medicaid to

Photo credit: March of Dimes Birth Defects Foundation

Congress could amend the Pregnancy Discrimination

Act of 1978 (Public Law 95-555) to close the loophole that

allows employers not to cover prenatal and maternity care

for adolescent daughters of employees covered by their

health benefit plans.

cover all poor adolescents, and a requirement that

employers provide health benefits to all workers

(and their families) working at least 30 hours

weekly) would insure approximately 78 percent of

uninsured adolescents. Even if appropriate benefits

are available, however, adolescents who are concerned about confidentiality may be reluctant to seek

care from providers if their private health plan

requires parents to submit a claim for reimbursement

(as most do), or present a parent’s Medicaid card to

obtain services. And providing ‘‘basic’ coverage

does not ensure that all adolescent health care needs

would be met.

Several strategies related to improving adolescents’ financial access to health services were

presented in conjunction with Major Option 1 (see

table 5). Additional options are presented in table 23.

Consent and Confidentiality Issues (ch. 17)

Parental consent and notification requirements

pose a significant barrier to some adolescents’

access to certain health services. Under common

l~TIt is lmpo~mt t. no[e t~t a preVIous rcpofl by OTA found no evidence that well-child care visits beyond those necess~ for immunizations w~e

cost-effective (225,) OTA 1988 report emphasized well-child care prior to adolescence, The current Report did not conduct a cost-effectiveness or

effectiveness analysis of the I]teraturc on well-child c.arc visits for adolescents. However, other attempts to do so have found no evidence that any

particular penodicity schedule is warranted by existing evidence on effectweness (see especially, 319).
I-112 ● Adolescent Health—Volume I

law, a minor cannot receive health services without

parental consent. State courts and legislatures, as

well as the U.S. Supreme Court,198 have carved out

various types of exceptions to the parental consent

requirement (e.g., for emancipated minors, for emergency health services, for services related to the

treatment of STDs, and for family planning and

abortion services),199 but the exceptions vary widely

from State to State and frequently vary for different

types of services within a State. In carving out

exceptions to the parental consent requirement, State

courts and legislatures have sometimes-though not

always-replaced the parental consent requirement

with a parental notification requirement. Courts and

legislatures seem to regard parental notification

requirements as less burdensome for adolescents

than parental consent requirements, but it is not clear

that adolescents who are in conflict with their

parents make this distinction.

In the case of family planning and abortion

services, studies have found that parental consent

and notification requirements pose a significant

barrier to adolescents’ access to and utilization of

services. Quite probably, such requirements also

pose similar barriers to adolescents’ access to other

types of services (e.g., mental health treatment, drug

abuse treatment, alcohol abuse treatment).

Parental consent and notification requirements

appear to be based on various rationales. One is that

such requirements foster the stability and cohesiveness of the family, something in which the state has

a legitimate interest, by bolstering family autonomy

and parental authority. Another is that minors as a

class are incompetent to give informed consent to

health care or to enter into contracts with physicians.

Little empirical research has been done on the

competence of minors to give informed consent to

health care. The research that has been done

suggests, but not conclusively, that adolescents ages

14 and older may have the capacity for informed

consent. This empirical research is consistent with

findings on cognitive development during adolescence.

200 

. More research on adolescent participation

in health care decisionmaking would be useful in

Table 23-Specific Options Related to Problems

in Adolescents’ Financial Access to Health Services

(ch. 16)”

Option 1: Improve adolescents’ financial access to health

and related services.

●

●

●

●

In considering any potential Medicaid physician payment

reform that results from the Physician Payment Review

Commission’s OBRA-89-mandated effort to examine the

adequacy of physician payment, physician participation, and

access to care by Medicaid beneficiaries, give high priority to

providers involved in direct service to adolescents.

Amend the Pregnancy Discrimination Act of 1978 (Public

Law 95-555) to dose the loophole that allows employers not

to cover prenatal and perinatal (maternity) care for adolescent daughters of employees in their health benefit plans.

Support private and public insurance coverage of nurse

practitioners and clinical nurse midwives and other nonphy -

sician providers to boost the availability of personnel to treat

adolescents and promote the financial viability of schoolIinked health centers and other adolescent health centers

designed to provide services to adolescents.b

Encourage the U.S. executive branch, a congressional

agency, or an independent nongovernmental entity to fund a

study to determine the elements of a model health insurance

benefit for adolescents.

aAlsosee Majoroption 1 related to improving adolescents’ -~to h~lth

and related services that was presented in table 5.

%hese personnel may need adolescent-specific training. Ses table 22,

“Specific Options Related to the Delivery of Primary and Comprehensive

r-tealth Servkxs to Adolescents.”

SOURCE: Office of Technology Assessment, 1991.

helping to inform considerations of what, if any,

changes would be appropriate in current State and

other laws and regulations governing consent and

confidentiality.

Given the array of laws pertaining to consent and

confidentiality that currently exist, adolescents—

and perhaps even providers—are understandably

confused about how these laws pertain to them as

individuals. If it chose to, Congress could intervene

to reduce these uncertainties by moving Federal and

State laws in the direction of greater uniformity.

Another way of reducing adolescents’ uncertainties

might be to encourage States, localities, and schools

to integrate information about the legal aspects of

access to health services in health education courses

for adolescents.

Several strategies related to improving adolescents’ legal access to health services were discussed

lgg~ws ~lat~ to tie ~]~ation of authority for decisions about the provision of health services to rninOrS hve hktOriCd@ kn the prOVinCe of Shte

legislatures, State courts, and State administrative agencies, but the U.S. Supreme Court decidm whether State laws comport with the U.S. Constitution.

l-eexWptiom tend to f~linto four categories: 1) exceptions for abused and neglected minors; 2) exceptions for emancipated, independent, or~ture

minors; 3) exceptions for health emergencies; and 4) exceptions for specitlc health problems and services (e.g., services related to sexual activities, to

drug and alcohol abuse treatment, and to mental health treatment).

‘See ch. 2, “What Is Adolescent Health?” in Vol. H.
Summary and Policy Options .1-113

Table 24--Specific Options Related to Concerns

About Consent and Confidentiality in Adolescent

Health Care Decisions (ch. 17)

Figure 22-Socioeconomic Status of U.S.

Adolescents Ages 10 to 18, by Family Income as a

Percent of the Federal Poverty Level, 1987a

Option 1: Improve adolescents’ legal access to health and

related services.a

Option 2: Support Federal data collection and research

related to the allocation of authority for adolescent health

care decisions.

● Support further research on adolescents’ capacities to make

various types of health care decisions, taking into account

factors such as age, prior experience, situational factors, and

intelligence.

. Support further research to determine the extent to which,

and under what circumstances, parental consent and notification requirements create barriers to adolescents’ access to

services other than family planning and abortion services

(e.g., treatment for sexually transmitted diseases, outpatient

mental health services, substance abuse treatment).

. Support research to determine the extent to which parental

prerogatives to hospitalize their children for mental health or

substance abuse problems causes harm to the adolescents.

asee ~~or Optlon I related to improving adolescents’ access to sertiCes

that was presented in table 5,

SOURCE: Office of Technology Assessment, 1991,

in conjunction with Major Option 1 (see table 5).

Additional options are presented in table 24.

Issues in the Delivery of Services to Special

Groups of Adolescents (ch. 18)

Certain groups of adolescents—adolescents living in poverty, racial and ethnic minority adolescents, and adolescents living in rural areas—

experience health problems at disproportionate rates

and face barriers to health care because of lack of

financial resources, limited local availability of

resources, or other factors.

Poor Adolescents

In 1987, nearly one-third of U.S. adolescents lived

in families with incomes that did not exceed 150

percent of the Federal poverty level (see figure 22).

One of the primary determinants of whether an

adolescent was living in poverty was living arrangement. Adolescents who were living with both

parents or with their father were far less likely to be

living in poor families than were adolescents living

with their mother only or adolescents living on their

own (see figure 23).

The effects of growing up poor are complex and

not well understood ( 152). It is well known, however, that children growing up in poverty confront

more risk factors and benefit from fewer protective

and supportive factors than their more advantaged

peers. Among the risk factors that many (though not

ncome 150-299%

ercent of poverty

8.959 million

(28.9%)

Income less than

150% of poverty

(poor and near-poor)

8.928 million

(28.8%)

aFamily i~me is expre=~ in relation to the Federal PovertY level. In

1987, the Federal poverty level was $9,058 for a family of three.

SOURCE: Office of Technology Assessment 1991, based on R. Kronick,

Adjunct Professor, University of California, San Diego, CA,

calculations based on U.S. Department of Commerce, Bureau

of the Census, March 1988 Current Population Survey public

use files. 1989.

Photo credit: Office of Technology Assessment

Dilapidated housing is among the stressful factors that

many poor adolescents confront.

all) poor children confront are a highly stressed and

disorganized family environment, dilapidated housing, substandard schools, and often, especially in

inner cities, dangerous, blighted neighborhoods

where crime and violence seem to have become the

norm (74). Access to health care for poor adolescents

appears to be limited, based on utilization data and

known barriers to access (e.g., low physician participation in Medicaid, problems with transportation,

lack of services in poor areas). Yet although the rates

of many health and related problems (e.g., days of
I-114 Adolescent Health—Volume I

Figure 23-Family Incomes as a Percent of the Federal Poverty Level

by U.S. Adolescents’ Living Arrangements, 1988a

Incomes of families in which adolescents

are living with both parents

Income 150-299%

of poverty

Incomes of families in which adolescents

are living with their father only

Income 1

ome less

( ncome less of po an 150%

than 150% (33. poverty

25.9%)

of poverty

(15.1%)

\

,//

//’

Income 300% and

above of poverty

(54.1%)

Incomes of families in which adolescents

are living with their mother only

Income less than

150% of poverty

(5

Income 150-299% (15.4%) -

of poverty

(27.6%)

Income 300% and

above of poverty

(40.4%)

Incomes of families in which adolescents

are not living with parents or

are married and living with

their parent(s)

Income less than

150% o

(57

300% and

Income 150-299% above of poverty

of poverty (18.8%)

(23.6%)

NOTE: Figures may not add to 100 percent because of rounding error,

aFamily i~~me is ~xpre=~ in relation to the F~eral poverty level, In 1988, the Federal povefly level WaS $9,431 for a family Of three.

SOURCE: Office of Technology Assessment, 1991, based on R. Kronick, Adjunct Professor, University of California, San Diego, CA, calculations based on

U.S. Department of Commerce, Bureau of the Census, March 1989 Current Population Survey public use files, 1990.

resticted activity due to acute and chronic condi- appear to survive their childhoods relatively untions, overall self-reported fair or poor health, school scathed.

dropout, adolescent pregnancy, cigarette smoking, Research on the predictors of resiliency among

involvement in serious forms of delinquency, vic- adolescents from disadvantaged backgrounds (intimization) are higher among poor than nonpoor eluding impoverished homes) is receiving increasadolescents, many, if not most, poor adolescents ing attention from researchers, although it has
Summary and Policy Options . I-115

received little Federal support. Past research on this

topic suggests that having access to supportive

individuals and networks, and the ability to draw

upon existing networks (e.g., through greater social

competence and intelligence), are important factors

in helping adolescents overcome adverse circumstances. For many adolescents these factors may be

amenable to intervention.

Racial and Ethnic Minority Adolescents

Currently, half of black, Hispanic, and American

Indian adolescents, and 32 percent of AsianAmerican adolescents, are poor or near-poor (below

150 percent of the Federal poverty level) (see figure

24). The disproportionate occurrence of health

problems that is found among adolescents in these

racial, ethnic, and tribal groups is attributable at least

in part to their poverty status, and the lack of access

to health care that is associated with being poor. A

long history of discrimination against people of

color may contribute to stress in racial and ethnic

minorities (e.g., 106,1 83).

Among the pressing prevention and service needs

for racial and ethnic minority adolescents include

preventive mental health and mental health outreach

programs for Hispanic, Asian, and American Indian

and Alaska Native adolescents; dental care and

fluoridation for American Indian and Alaska Native,

and Hispanic adolescents; dental care for lowincome bIack adolescents; victimization and violence prevention for black adolescents in poor

neighborhoods; pregnancy prevention services for

black and Hispanic adolescents; HIV prevention and

treatment services for black and Hispanic adolescents. In general, however, these problems are not

restricted to these groups, and the sources of the

problems are not related to race per se (e.g.,

genetically based), but to complex interactions

among economic, neighborhood, and societal factors.

There is an increasing consensus that services for

racial and ethnic minority adolescents would be

improved if they were ‘‘culturally competent.

Culturally competent services for adolescents may

be difficult to design, though, because there is little

systematic information about how racial and ethnic

minority and poor adolescents experience adolescence. There is beginning to be some systematic

analysis of what a culturally competent system of

care is, but the knowledge base has not yet been

applied systematically to the design of training

- - s “- -+ . .

Photo credit: © Ted Kirk/Education Week

Some research suggests that adolescents who live on

farms are particularly unlikely to have access to sources of

health care.

programs for health care and other service providers.

Overall, there is little systematic description of how

services have been developed or adapted to meet the

specific needs of racial and minority adolescents,

and less scientific evaluation of the effectiveness of

available services. There are, however, very few

health care providers who are racial or ethnic

minorities. The number who are racial and ethnic

minorities and trained to work specifically with

adolescents is not known.

Rural Adolescents

With the exception of the higher rate of accidental

injuries (due in part to farm injuries) and lower rate

of delinquency for adolescents living in rural areas,

there are few known sizable rural-urban differences

in adolescent health. Although research on adolescents living in rural areas is limited, this suggests

that rural adolescents are at least as likely to

experience many of the same health problems

experienced by adolescents in metropolitan areas.

However, additional descriptive research designed

to separate rural, regional, social class, and ethnic

factors is needed, in addition to analyses to determine the possibly differential effects of particular

dimensions of rural life (e.g., living on a farm v. in

a town) on adolescent health and well-being.

Rural adolescents’ access to health services is

limited by shortages of professionally staffed mental

and physical health services, transportation problems, and less access to Medicaid in rural States

(233). Thus, adolescents in rural areas are especially

likely to receive their health care from hospital
I-116 ● Adolescent Health—Volume I

Figure 24-Family Incomes as a Percent of the Federal Poverty Level by U.S. Adolescents’ Race/Ethnicity, 1988a

White, non-Hispanic Asian

Inco

o

Income less than

e less than

of poverty

150% of poverty 32.0%)

(17.3%) Income 151-299%

of poverty

(25.0%)

up~’:~~.y’$e

Income 300% of

poverty and above

(52.4%)

Hispanic

Income less t

150% of pove

(49.0%)

Income 300% of

Income 151-29 overty and above

of poverty (19.5%)

(31.5%)

Black, non-Hispanic

Income less than

150% of poverty

(52.1%) /

Income 151-299%

of poverty

(26.9%)

L-’’” P

Income 300% of

overty and above

(21.0%)

Income less than ~

150% of poverty i

(51.0%)

American Indians

and Alaska Natives b

/

Income 300% of

Income 151-299%

poverty and above

(17.0%)

of poverty

(31.0%)

aFamily ~nmme is expressed in relation to the F~eral ~verty ~vel. In 1 We, the Federal poverty level W- $9,431 for a family Of three.

bBecauseofthesmall number of American Indians and Alaska Natives sampled forthe Current Population Survey and various limitations of thesurveydesign,

the estimates for this group may be unreliable. The proportion with incomes iess than 150 percent of poverty could be between 41 to 61 percent (1 11).

However, the high rate of poverty among American Indians and Alaska Natives found through the Current Population Survey is consistent with estimates

from other sources (223).

SOURCE: Office of Technology Assessment, 1991, based on R. Kronick, Adjunct Professor, University of California, San Diego, CA, calculations based on

U.S. Department of Commerce, Bureau of the Census, March 1989 Current Population Survey public use files, 1990.
Summary and Policy Options . 1-117

Table 25-Specific Options Related to the Delivery of

Services to Poor Adolescents, Racial and Ethnic

Minority Adolescents, and Rural Adolescents (ch. 18)

Option 1: Improve access to health and related services

among poor adolescents, disadvantaged racial and ethnic

minority adolescents, and rural adolescents..

●

●

●

●

●

●

●

Expand support for training of racial and ethnic minority,

rural, and low-income health care providers with an interest

in adolescent health care.

Support training in cultural competence for health care

providers who work with racial and ethnic minority adolescents, incorporating evaluations of the effects of such training.

Support preventive mental health and mental health outreach programs for Hispanic, Asian, and American Indian

and Alaska Native adolescents.

Increase support for dental care for American Indian and

Alaska Native, Hispanic, and low-income black adolescents.

Support injury prevention efforts targeted to rural and

American Indian adolescents.

Support homicide and violence prevention efforts targeted to

male adolescents living in inner cities.

Support innovative efforts (accompanied by rigorous evaluation) to increase rural adolescents’ access to health care

services (e.g., school-based youth services centers, im

proved transportation, use of nonprofessionals, dissemination of information about availability of local health services).

Option 2: Support Federal data collection and research

related to selected groups of adolescents.

Data collection:

. Support the expansion of data collection efforts to oversample racial and ethnic minority adolescents and to include

information on socioeconomic status.

. Collect data on the availability and accessibility of health

services for racial and ethnic minorities, rural, and poor

adolescents, with such research to include adolescent

perceptions of accessibility and availability.

Research:

. Support research on the impact of racial and ethnic minority

status and poverty on adolescent health and development,

including health beliefs and practices. Include the effects of

rural poverty. Such research should attempt to ascertain the

positive, as well as negative, aspects of racial and ethnic

identification and all strata of socioeconomic status, and such

research should be conducted in such away that the effects

of racial and ethnic minority status can be distinguished from

socioeconomic status.

. Support evaluations of the use of nonprofessionals to

provide health and related services to rural, minority, and

poor adolescents.

Option 3. Foster changes in adolescents’ environments.

Support fluoridation of drinking water supplies in the Southwest.

Support efforts to improve environments in poor areas

(including hard-hit farm belt communities, Indian reservations, and inner cities), focusing on family support, improving

school environments, improving dilapidated housing, increasing access to nutritional food, increasing access to

recreational and fitness facilities and activities, and increasing access to appropriate adult role models.

asee Major Option I related to improving adolescents’ acxxssto health and

related servrces that was presented in table 5.

SOURCE: Office of Technology Assessment, 1991.

clinics, and are relatively unlikely to have any

consistent source of care (132). Some research

suggests that adolescents who live on farms are

particularly unlikely to have access to sources of

health care (323). Innovations in efforts to provide

more comprehensive and integrated services will

have to be adapted to the specific needs of rural

adolescents, and specific limitations in health care

resources (e.g., the relative scarcity of health care

professionals).

Options related to the delivery of services to, and

the improvements of environments for, poor adolescents, racial and ethnic minority adolescents, and

rural adolescents are presented in table 25.

The Role of Federal Agencies

in Adolescent Health (ch. 19)

OTA’s analysis of Federal expenditures and

efforts on behalf of adolescents finds that, with some

condition-specific exceptions (e. g., drug use), attention to adolescent concerns has been weak and

fragmented. Most Federal agencies do not provide

specific budget lines for adolescents but include

adolescents as part of a larger, more general,

research or service focus. Within DHHS, for example, it is rare for an agency to devote more than 10

percent of its expenditures specifically to adolescents. 201 In those agencies outside of DHHS, adolescent issues tend to receive a larger proportion of

appropriated money, although the total amounts are

small.

Because adolescents require comprehensive, continuous, developmentally appropriate, labor-intensive interventions, they may not be receiving the

services they need when they are included as part of

programs serving children in general or adults. On

the other hand, it is important to view adolescents as

part of a life-span continuum and not separate them

inappropriately from other age groups. What has

occurred, however, is a somewhat scattershot approach neither intensively oriented toward adolescents as a specific population nor attentive to the

relationships between other developmental periods

and adolescence. Thus, as opposed to some specific

behaviors engaged in by some adolescents and

judged to be both prima facie unacceptable a n d

characteristic of adolescents as a group, adolescents

20 l~e Centers for Dlseasc Control D1\, ision of Adolc~cnt ~d Schoo] Health, tie National Instimtes of Heal~’s National Institute Of Allergy and

Infectious Diseases, and the Alcohol, Drug Abuse, and Mental Health Administration’s National Institute of Mental Health are the exceptions.
I-118 ● Adolescent Health—Volume I

do not appear to have a high priority on the Federal

agenda.

Several strategies related to the Federal role in

adolescent health were discussed in conjunction

with Major Option 2 (see table 6). An additional

option is presented in table 26.

Barriers and Opportunities to Change

Both barriers and opportunities become apparent

in considering the potential for change in approaches

to adolescent health. This analysis focuses on

barriers and opportunities particular to national

public policy, but many of the same points are

relevant to actions that can be taken by the numerous

actors responsible for adolescent health: parents,

schools, community leaders, State and local governments, private sector organizations, and adolescents

themselves.

Although they are for the most part interrelated,

the primary barriers to change can be characterized

as having to do with characteristics of the contemporary health service delivery system, with the Federal

budget deficit, and with science policy. Barriers

related to attitudes toward adolescents were discussed earlier (see “A New Approach”). Opportunities include the renewed attention to adolescent

health concerns in a variety of public and private

initiatives and concerns about the changing nature of

the workforce and the country’s economic future.

Barriers to Change

Health Care System

Brindis and Lee recently summarized the important factors that shape health-related American

public policy (25). These factors—which Brindis

and Lee summarized as ‘‘the American character’

—include such American ideals as individualism,

freedom of choice, the right to bear arms, freedom of

expression, capitalism, and competition, as well as

attitudes about dominance of the private sector and

the marketplace and the limited role of government

in solving economic and social problems. According

Table 26-Specific Options Related to the Role of

Federal Agencies in Adolescent Health (ch. 19)

Option 2: Support Federal research and data collection

● Stipulate that certain rigorous methodological criteria be met

for demonstration projects, especially in topic areas that

currently receive high levels of resources (e.g., prevention of

drug and alcohol abuse, pregnancy prevention).

SOURCE: Office of Technology Assessment, 1991.

to Brindis and Lee, the American character ‘is a key

factor affecting choices available to policymakers,

including choices about adolescent health.

The American values that shape public policy

have also helped to shape the American health care

system, which has emerged as pluralistic and

dominated by the private sector (25). Two other

concepts that can be used to characterize the current

health care delivery system are stance and concept

(332). The health care delivery system takes a

“waiting” rather than a “seeking” stance (332):

The waiting mode is characterized most strongly

by professionals physically remaining within a

service system and, indeed, waiting for clients,

generally with chronic problems, to come to them.

. . . The seeking mode describes a style where

professionals are usually physically operating outside the service system and seeking to intervene in

problems before they become chronic. However, in

practice, it is acknowledged that waiting/seeking is

best thought of as a continuum, and less as a

dichotomy.

Consistent with the waiting stance, most health care

interventions (including preventive interventions)

are focused on the individual or interpersonal levels,

rather than organizational/institutional or environmental levels.

As discussed above, adolescents face issues

common to other age groups, and other barriers

unique to them (see table 1 in “Major Findings’ ‘).

Unique barriers include legal barriers to access, lack

of confidentiality, lack of income that would support

payment for the health and related services that they

might choose, 202 and lack of the information that

would make them effective consumers of health

202Althou@ ~~ts my Imk the ~come it would take to gain access to needed or desired health care senfices, the sdal status of adults is such that

they have greater opportunities to earn income than adolescents do. Depending on their age and other circumstances (the cost of the care being sought),

adolescents’ opportunities to earn a sufficient income to support themselves and gain independent access to health services are limited by restrictions

on their ability to work (e.g., because of child labor laws) and low earnin g levels (e.g., typically minimum wage or, perhaps appropriately, entry level

wages). In additio% adolescents are typically not eligible to get credit on their own until they reach the age of majority (18 in most States; see ch. 17,

“Consent and Confidentiality in Adolescent Health Care Decisionmaking,’ in Vol. III). Some adolescents, of course (e.g., those who do have a relatively

high paying job, who save money obtained through gifts, or who receive a generous allowance, or otherwise have an independent source of funds), would

have enough income to gain access to at least some health care semices.
Summary and Policy Options . I-119

care. In addition, adolescents may be particularly

affected by the tendency of the health care financing

system to emphasize treatment for full-blown clinical problems over secondary prevention through

early intervention for subclinical problems. Many of

the services that adolescents need are lowtechnology, time-intensive services that are generally not well-supported by current financing mechanisms, and thus not profitable to provide. Although

the nature of financing health care is changing

somewhat in the direction of increasing support for

cognitive services, 203 the financial predominance of

high technology interventions does limit the amount

of change that could be expected in the delivery of

health services to adolescents,204 unless an extraordinary effort is expended to manage the health care

of adolescents differently from that of other age

groups.

Federal Budget Deficit

In part as a result of the Federal budget deficit—

estimated to be $220 billion at the end of fiscal year

1990 (316)--Federal social policy expenditures are

generally in a ‘‘no-growth’ phase. Although there

was by some accounts a substantial increase in

discretionary domestic spending between 1989 and

199 0

205206 (212), the Budget Enforcement Act of

1990 (Title XIII of OBRA-90) established spending

limits on discretionary spending for 5 fiscal years

(from fiscal years 1991 through 1995) (215). For the

category of domestic spending for fiscal years 1991

to 1993, the limits were such that discretionary

programs would grow only at the expected rate of

inflation. 207 Thus, by law, domestic discretionary

spending can rise from $198.3 billion to $210.1

billion (6 percent) between fiscal years 1991 and

m~In c)BRA.89, COngreSs, following the r~ommendation of the Physician Payment Review Cornmissior+ adopted a‘ ‘resource-based’ fw sch~ule

as the basis for paying physicians for Medicare Part B (outpatient) semices. This will incrtme payments for primary care semices and reduce some

payments for technical services (e.g., surgery), Primary care serwces tend to involve more interpersonal interaction than do high technology services.

The new payment method is expected to increase Medicare rtvenues to specialities for which primary care services are a substantial part of practice,

such as farmly practice and internal medicine (170). At present changes following the recommendations of the Commission apply only to the Medicare

program. However, the Commission has recently been mandated to consider physician payment under Medicaid (170). In additio~ health care financing

changes adopted by the Federal Governrn ent sometimes act as a catalyst for change in the private health insurance sector.

~For emmple, ~~ough such imovatiom~ ~ school.linked h~~ cent~s ~ve ~Wn to ad~ess some of tie n~ds of adolescents without my SOUIC(3

of payment for services (i.e., without health insurance (see ch. 15, “Major Issues Pertaining to the Delivery of Primary and Comprehensive Health

Services to Adolescents, in Vol. III)), it has been observed that at least some school-linked health centers tend to follow the prevailing ‘waiting’ model

of providing health care services (e.g., not providing sufficient outreach) (105). Some have observed that school-linked health centers work best when

they are integrated into the “life” of the school (e.g., 29). In addition, the Center for Population Options’ study of school-linked health centers located

in schools observed that cost-saving measures engaged in by school-linked health centers lead to heavy staff turnover, reducing the continuity of the

relationships that can be developed between the staff and students (105).

~~DiL~C-r~(/~nu~ domcs[ic social welf~ prOgrZIIIM (including health programs) consist mostly of g~ts tO s~tes fO1 education, mining, ~ployfnen~

and social services, ccrt.ti(, health care services, and some food assistance programs (47,21 8). Domestic discretionary programs include social progrants

such as Head Start, the Job Training Partnership Act, Compensatory Educauon, Student Financial Assistance, Handicapped Educatiow Alcohol, Drug

Abuse, and Mental Health programs, Special Supplemental Food Program for Wome~ Infants, and Children, the Child Care Development Block Grant,

Vocational and Adult Education, low-income housing, and nonsociul programs such as Highways, the Federal Aviation Administration, the National

Aeronautics and Space Administratio~ the Drug Enforcement Task Force, the Federal Prison System, and the Drug Enforcement Administration

(2 12,21 8). The largest social welfare programs are legal entitlemen~s (218).

m~Firrn estimates of discretionary socia/ spending for fiscal year 1990 (for the purposes of comparing such spending to fis~ Yeti 1991 ad ~Yond)

are not avadablc, The Office of Management and Budget estimated an 11.7-percent increase in overall social we~are spending between 1990 and 1991

(not adjusted for inflation), compared to the 8.9-percent increase that occurred between 1989 and 1990 (318). (The Congressional Research Semicc

included m the total for social welfare spending the following categories and estimated the following changes between 1989 and 1990, adjusted for

inflation: social security (1,8-percent increase); Medicare (9. (j-percent increase); income security (3.8-percent increase); health (14.4-percent incrca.se

[includes Medicaid]; cducatio~ training, employment and social services (2.7-percent decrease); and veterans’ benefits (7.8-percent decrease) [218],)

The House Budget Committee reported the following fiscal year 1991 increases in budget authority over fiscal year 1990 levels for selected domestic

discretional programs: Head St,art ($400 million); Job Training Partnership Act ($ 143 million); Compensatory Education ($857 milIion); Handicapped

Educa~on ($390 million); Alcohol, Drug Abuse, and Mental Health Administration ($256 million); Assisted Housing ($1,801 million); Special

Supplemental Food Program for Wome~ Infants, and Children ($224 million) (2 12).

mTFor fl~c~ years 1994 ad IW~, the llmlts on new budget authority and outlays are established only for total discretion~ spending (21s) 1n tie

fourth and fifth ~wtrs of the 5-year accord enacted into law under OBRA-90, “the $115 billion in savings would be allocated between military and

nonmilitary accounts by House and Senate appropriations committees’ (237).
i-120 ● Adolescent Health—Volume I

1992 and from $210.1 billion to $221.7 billion (5.5

percent) between fiscal years 1992 and 1993 (215).208 209

The fact that the Budget Enforcement Act wrote

into law separate spending limits for military,

domestic, and foreign aid discretionary spending

programs for 1991, 1992, and 1993, means that

spending increases in any one domestic category

would essentially have to come from decreases in

another domestic category.

Of primary concern in deficit reduction are efforts

to reduce spending on health care (e.g., 238).210 A s

a result of an aging population, advances in technology, and other factors (222), national health expenditures continue to increase, from 7 percent of the

gross national product in 1970 to 11.1 percent of the

gross national product in 1987 (254,261).211

Limitations of Prevailing Approaches to

Program Design and Evaluation

Another barrier to progress in improving interventions designed to enhance adolescent health can be

found in current approaches to program design and

evaluation. Cook and his colleagues are preparing a

critique of the current approach as it applies to social

science research in general, and adolescent health

evaluation research in particular, for the forthcoming Carnegie Corporation-sponsored volume, Adolescent Health Promotion (41), and their comments

will provide a useful framework for thinking about

theoretical development in adolescent health services, program design, and evaluation.

Cook et al. argue that the design, implementation,

and evaluation of services for many complex,

socially determined, adolescent health problems are

not amenable to the almost universally accepted

medical framework. According to Cook et al., the

use of the randomized clinical trial-the preferred

approach in the medical and health sciences field—

as the model for evaluation is inappropriate because

it “seeks to identify the consequences of a small

number of manipulanda [variables] taken individually or as a small number of statistical interactions. . .The [randomized clinical trial] model does

not attempt to develop a complete causal model of

any outcome’ (41). Instead, Cook and his colleagues propose a theory of evaluation predicated on

the “primacy of causal explanation. ” If this theory

were followed, evaluation research would be used to

simultaneously evaluate prevention and treatment

interventions and develop complex models of the

causes of behaviorally and socially related adolescent health problems.

It is important to note that Federal programs

currently fund, and as a correlate, individual investigators typically design, studies that follow the

medical model. Maintaining this framework for

funding for a limited set of conceptualizations of

adolescent health will not advance the field very

much.

Opportunities To Change

Renewed Attention to Adolescent Health Concerns

At the same time that general attitudes toward

adolescents continue to be unsympathetic, a number

of public and private initiatives have begun to

change the terms of the debate about adolescent

health. These include private foundations such as the

Carnegie Corporation of New York and its Carnegie

Council on Adolescent Development (28,29,51,62,137),

the MacArthur Foundation (funding studies in

successful adolescence in high-risk environments),

the Robert Wood Johnson Foundation (180), the

Ford Foundation (66), the Annie E. Casey Foundation, the Charles Stewart Mott Foundation

ms~e spending limits shown refl~t the adjustments (e.g., for Internal Revenue Service tax compliance funding) that the office of Wgment @d

Budget was authorized to make when it submitted its fti ‘sequestration report’ for f~al year 1991; these adjustments were made after the adjournment

of the IOlst Congress, 2d session+ on Oct. 27, 1990 (215; also see, Title XIII, Public Law 101-508). For updates of the ~lce of Management and Budget

adjustments, which in the aggregate increased the domestic caps by very small amounts, see the President’s Budget for fiscal year 1992 (318). It may

be important to note that the discretionary caps were set in terms of dollar amounts and not percentages as a function of inflation.

=fense spending was projected to d ecrease 0.7 percent between fiscal years 1991 and 1992, and another 1 percent between fiscal years 1992 and

1993. Even so, discretionary defense spending would remain greater than discretionary domestic spending ($297 billion in fiscal year 1991).

zi~or emple, OBRA.90 pared Medicare $42.4 billion over 5 years, with an anticipated $10 billion CO@ fiOIIl increased costs to beneficiaries,

and the remainder coming from reduced reimbursements to physicians and hospitals. Spending for Medicaid was projected to be cut $607 million over

5 years by requiring drug companies to offer price discounts to those in the program.

211~ 1988, expndi~es for h~~ -in he United Swtes we~ est~t~ to tow $539.9 bi~ioq a lo-per~nt incr~e from the previous y~ (254).

Eighty-eight percent of this amount was for so-called personal health care-including 39 percent for hospital care, 19 percent for physician scnvices,

8 percent for nursing home care, and 22 percent for other personal health care (other professional services, home health care, drugs and other medical

nondurable, vision products and other medical durables, and other), and 12 percent was for research constructio~ program adrrmM“ “stratiom the net cost

of private health insurance, and public health activities (254).
Summary and Policy Options .1-121

(31,32,33,131,167), The Edna McConnell Clark

Foundation (118), the W.T. Grant Commission

(330), the Lilly Endowment (e.g., the Youth as

Resources program (155)), the Milton S. Eisenhower Foundation (138) and the W.K. Kellogg

Foundation (334).

Several States have developed special youth

initiatives (52), and some State coordination efforts

were supported by the short-lived Federal initiative,

Youth 2000 (314).

On the Federal level, the Centers for Disease

Control in DHHS now has a Division of Adolescent

and School Health, and has provided substantial

funding for the development of a Youth Behavioral

Risk Factor Survey. The National Institute on Child

Health and Human Development (within DHHS’

National Institutes of Health) is developing plans for

an adolescent program (3). In 1990, adolescent

health was the theme of the DHHS-sponsored Child

Health Day, The President’s Budget for 1992 noted

that Federal spending to benefit children (no ages

specified) has grown far less quickly than spending

on adults; it estimated that Federal spending on

children has been essentially level (at about $100

billion in 1992 dollars) from 1976 to 1989, while

Federal spending on adults rose from less than $100

billion in 1960 to about $525 billion in 1989 (1992

dollars) 2

1

2 (3 18). A major theme of the President’s

budget message was “Focusing on Prevention and

the Next Generation’ (318).

Separate estimates for spending on adolescents

were not provided in the 1992 budget proposal,

however, and many of the proposed funding increases focused primarily on younger children (e.g.,

programs to reduce infant mortality, childhood

immunizations, prevention of lead poisoning). 213

The focus of the entire prevention initiative was on

“individual behavior and personal responsibility’

and ‘‘fostering a climate of personal responsibility”

(318). In total, the administration estimated that its

proposed budget would result in an increase of 9.5

percent for programs serving children; however,

many of these programs (77 percent of the overall

Photo credit: UAW-Ford National Education,

Development and Training Center

Several private and public adolescent health initiatives

have been stimulated by concerns about the changing

demographics of the country, including the changing

nature of the workforce and the implications of these

ohanges for the country’s economic future.

spending on children) are mandatory (entitlement)

programs; thus, increases in discretionary spending

are quite limited (3 18). Nevertheless, the recognition that children have been underbenefitted relative

to other age groups can be considered encouraging.

Concerns About the Changing Nature of the

Workforce and the Country’s Economic Future

Several, if not most, of the private and public

adolescent health initiatives, including this Report,

have been stimulated at least in part by concerns

about the changing demographics of the country,

including the changing nature of the workforce and

implications of these changes for the country

economic future. The U.S. population is becoming

older, and more culturally and ethnically diverse

(240,242,328). The outlines of the impact of the

change in age ratio on the Nation’s economic future

can be seen in the changing dependency ratio214 (see

figure 25). Beginning in the year 2010, increases in

212~C Soumes of these ~stimate~ (lnclud~g ~es of progr~) were not provid~, and OTA did not attempt to evaluate their accuracy.

213find1ng inCrwSeS ~~ a ~tential]y more &Wt application to adol~~nt needs included injq prevenhon progr~ (a 13-percent increase, fim

$1,683- to $1,907 -rnillio& although this included transportation safety programs such as the Federal Aviation Administration and the Coast Guard);

family planning (a 5.2-pereent increase, from $399- to $42@million, affecting the Public Health Service family planning grants and the Medicaid

program); and smoking cessation (a 7.7-percent increase, from $90- to $97-millio~ affecting the National Institutes of Heal@ the Alcohol, Drug Abuse,

and Mental Health Administration and the Centers for Disease Control).

zl~~e deWndency ratio is the number of childr-m and elderly people per every 100 people of working age.
I-122 ● Adolescent Health—Volume I

Figure 25-Changes and Projected Changes in the

Number of Dependents per 100 Persons of-Working

Age, 1960 to 2040

Number of dependents per 100

100

80

60

40

20

0

Persons of working age

81.6

78.0

w~,

16.7 17.4

64.6 61.7 60.0

18.6

~E Fq

66.6

20.3 20.

21.8

64.9

60.6

46.0

L

41.4 39.2

1

34.7

—

64.1

l!!!!! 29.1

35.0

73.9 74.2

1960 1970 1980 1990 2000 2010 2020 2030 2040

Year

.~ Children = Elderly

SOURCE: Office of Technology Assessment, 1991, based on U.S. Depart

ment of Commerce, Bureau of the Census, Pro@etions of the

Population of the Unifed States, by Age, Sex, and Race: 1988

to 2080, Current Population Reports Series P-25, No. 1018

(Washington, DC: U.S. Government Printing Officer January

1989).

the number of elderly dependents and decreases in

the numbers of working age individuals will cause

the overall dependency ratio to rise.215

The overall, child-dependent, and working-age

populations are changing in racial and ethnic makeup, as well. In 1982, approximately 73 percent of the

U.S. population was white, non-Hispanic; by the

year 2010, the proportion is expected to decline to 64

percent; and by the year 2080, only 43 percent of the

U.S. population is expected to be white, nonHispanic (246).216

While the greatest impact on the dependency ratio

will be occurrin g in the proportion of nonworking

elderly, most of the increases in Hispanic and/or

nonwhite populations will be occurring as a result of

higher fertility (72). Thus, large increases in the

proportion of Hispanic and/or nonwhite children

Figure 26-Projected Changes in the Racial and

Ethnic Makeup of the U.S. Population Under Age 18,

1982 to 2080

Percent of the total population, projected

80 -~ I

‘:k~

1982 1985 1990 1995 2000 2010 2020203020502080

Year

~ Other races — Spanish origin

— Black ~ White, non-Hispanic

SOURCE: U.S. Department of Commeree, Bureau of the Census, Projections of tfre Hispanic Popul&”on: 1983 to 2080, Current Population Reports, Population Estimates and Projections, Series

P-25, No. 995 (Washington, DC: U.S. Government Printing

Office, January 1986).

have been projected. The Hispanic 217 and/or nonwhite population below age 18 is expected to grow

from 26 percent in 1989 (246), to 33 percent in the

year 2000, and to 45 percent by the year 2080 (see

figure 26) (246).218

White participation in the labor force is expected

to grow more slowly than that of blacks, Asians and

others, and Hispanics, reflecting slower rates of

population growth and an older age structure among

non-Hispanic whites (72). In the year 2000, for

example, only 31.6 percent of new entrants to the

workforce will be white, non-Hispanic, males, 219

while such males will represent nearly half (an

estimated 48.2 percent) of those leaving the

workforce (72). 220 By the year 2000, 26 percent of

the labor force is expected to be Hispanic and/or

nonwhite (see figure 27) (72). Forty-seven percent of

the labor force is expected to be female (72).

Zlssince 1970, when there were 81.6 dependents (children and elderly people) for every 100 people of working age, the dependency ratio has ~n

deelining, largely because of a rather precipitous decline in the child dependency ratio.

216A] though somew~t old, these wc the latest available census projections. Available data horn the 1990 CenSuS SUppOrt the gist Of ~~e probations,

however (248).

21@erso~ of Hispanic origin may be Of my mce.

zlg~ew projections ~e ~m a 19WS Census repo~ and thus may be somewhat dated. However, these are the latest available projections tilt brealc

out individuals of Hispanic origin. The 1989 Census report on projections only reports data for whites, blacks, and total population (242).

zl~eWmn 1988 and 2(KI0, 15 per~nt of new entrants are expected to be Hispanics, 13 percent are expeeted to be blach 6 percent are expected to

be AsiU and 35 percent are expected to be white, non-Hispanic wornen (72).

zz~e pmW~on of white ~les in tie workforceis a traditional benchmark, at least in part because male participation has been less subject to c@m

as a result of societal forces (e.g., choice, the availability of child care, or discrimination).
Summary and Policy Options . /-123

Figure 27—Projected Changes in the Racial, Ethnic,

and Gender Makeup of the U.S. Labor Force,

1988 to 2000

Percent of labor force

100 r 1

60

I

40

t

20

I

O

L

79

Ez2

1988 I

2000

—

White, non- Black Hispanic Asians Males, Females,

Hispanic & others all races all races

Racial\ ethnic and gender groups

aThema]e.female proportion may Vary somewhat by race and ethniC grOup.

For example, between 1988 and 2000, more of the Hispanic entrants to

the labor force are expected to be males, and more of the black entrants

are expected to be females.

SOURCE: H.N. Fullerton, “NewLaborForce Projections, Spanning 1988to

2000,” Monthly Labor Review, November 1989.

In many respects such cultural and gender diversity can only be welcome in the country and in the

workplace. However, these trends have raised concerns for several reasons addressed in this Report

and elsewhere (38,330), Perhaps most important,

currently half of the adolescents in three out of four

of the largest racial and ethnic minority groups

(American Indians and Alaska Natives, 221 blacks,

and Hispanics) in the United States live in poverty

(see figure 11 in “Major Findings” and 24 in

“Issues in the Delivery of Services to Selected

Groups of Adolescents’ ‘). 222 Poor racial and ethnic

minorities are both the least likely to complete

school and the most likely to experience the health

problems that are likely to interfere with optimal

functional development and ability to contribute to

the Nation’s productivity (e.g., adolescent parenting; incarceration for delinquency; violence (see

appendix B, ‘ ‘Burden of Health Problems Among

U.S. Adolescents, ’ in Volume III)).

Attention to concerns about the future may

prompt those responsible for public policymaking to

act to improve the health and well-being of adoles4

1 I

II

~.

*.

.4q- J

.+ .. &.&

Photo credit: Office of Technology Assessment

Adolescents who are both poor and members of racial or

ethnic minorities are more likely to be without the

necessary safety nets that help the typical adolescent

through the second decade of life, but even white middleclass adolescents are at risk of developing problems and

not having access to needed health services and other

sources of support.

cents in general, as well as the health and well-being

of the most disadvantaged.

Conclusion

Despite well-entrenched barriers to implementing

changes in approaches to promoting and improving

adolescent health, OTA found that change is essential. The social and economic costs to today’s

adolescents, and to the Nation, of not making

improvements in the Nation’s approach to adolescent health issues may not be quantifiable, but they

are potentially enormous. Adolescents who are both

poor and members of racial or ethnic minorities are

more likely to be without the necessary safety nets

that help the typical adolescent though the second

decade of life, but even white middle-class adolescent are at risk of developing problems and not

having access to needed health and other sources of

support.

OTA concludes that a more sympathetic, supportive approach to adolescents is needed. Should

society take such an approach, which includes taking

a more participatory approach to adolescent problemsolving, more concrete steps to help improve adolescent health will become apparent. OTA’s analysis

suggested three tangible approaches that could also

Z I Half of all American Indians and Alaska Native adolescents also live in poverty. While the total population of American Indians and Alaska Natives

is numencatly small, half are age 19 or under (22/3).

~ZUnfo~una[cly, tie Bureau of Labor Statistics does not report labor force pardcipation projections by socioeconomic Status. The combimtion of mcial

and ethnic minority status and poverty is discussed in ch, 18, “Issues in the Delivery of Services to Selected Groups of Adolescents, ” in Vol. III.
I-124. Adolescent Health—Volume I

be taken to benefit adolescents: improving access to

health services; restructuring and invigorating

the Federal role in adolescent health; and improving adolescents’ environments. Each of these

approaches can be addressed in numerous ways,

many outlined in this Report. This Report, comprehensive as it attempted to be, does not pretend,

however, to have all the “answers’ to the wellremarked upon crisis in adolescent health. Many of

the problems are in fact socially defined; others

clearly are not, and others will change as new

generations of children reach adolescence. Development of the solutions to problems, should they

continue to be considered problems, will undoubtedly be an iterative process.

Photo credit: Benjamin Smith, Washington, DC
APPENDIXES
Appendix A

METHOD OF THE STUDY

Overview of Publications

OTA’S Report, Adolescent Health, is being

in three volumes:

. Volume I. Summary and Policy Options;

published

. Volume II. Background and “the- Effectiveness of

Selected Prevention and Treatment Services; and

. Volume 111. Crosscutting Issues in the Delivery of

Health and Related Services.

A full table of contents for all three volumes appears in

box A-1.

OTA’s assessment on adolescent health also includes

two other publications. One, a Report entitled Indian

Adolescent Mental Health, was released in January 1990.

This Report analyzed the mental health needs of Indian

adolescents and the services available to address them.

The second publication, a background paper entitled

Adolescent Health Insurance Status, was prepared by

Richard Kronick and was released in July 1989. This

background paper looked at how many adolescents are

uninsured, why some adolescents are insured and others

are not, the change in the number of uninsured adolescents

over time, and the effect of selected potential policy

changes in reducing the number of uninsured adolescents.

Several papers were prepared under contract in the course

of this assessment, and those papers are listed in the

“Contractor Papers” section below.

Request for the Study

This OTA assessment of adolescent health was prompted

by several concerns, many of them arising from the

recognition that today’s youth wiIl someday support an

expanding aging U.S. population. Within this context,

OTA was asked to address the following topics:

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the health status of adolescents;

factors that put adolescents at risk for health problems or protect them from such problems, including

racial and ethnic backgrounds, socioeconomic status,

gender, and developmental stage;

issues related to the organization of health care

services and technologies available to adolescents,

including accessibility and financing;

issues related to the monitoring of adolescent health

and opportunities for improving national data collection of efforts; and

gaps in research on the health and behavior of

adolescents and opportunities for public and private

support.

OTA’s adolescent health study was requested principally by Senator Daniel K. Inouye, Chairman of the

Senate Select Committee on Indian Affairs, and Senator

Nancy L. Kassebaum, Ranking Minority Member of the

Subcommittee on Education, Arts, and Humanities of the

Senate Committee on Labor and Human Resources. Other

requesters included Chairmen and/or Ranking Minority

Members of the Senate Appropriations Committee, the

Senate Commerce, Science, and Transportation Committee, the Senate Finance Committee, the Senate Labor and

Human Resources Committee, the Senate Small Business

Committee, the Senate Veterans’ Affairs Committee, and

the House Interior and Insular Affairs Committee. The

requesters included the Chairman and six senatorial

members of the congressional Technology Assessment

Board (see box A-2). The Technology Assessment Board

approved the proposal to study adolescent health in June

1988, and OTA staff began working on the project in July

1988.

Involvement of a Nonprofit Foundation

An unusual feature of OTA’s adolescent health assessment was the involvement of a nonprofit foundation. On

August 4, 1988, Carnegie Corporation of New York

agreed to assist OTA in carrying out the assessment of

adolescent health. The Carnegie Council on Adolescent

Development, an operating arm of Carnegie Corporation

of New York, provided various types of assistance for

OTA’s Report, including assistance in the provision of

data, support for workshops and various contractors,

consultation and professional advice, and detailees to

assist with research and writing.

Advisory Panel and Reviewers

Advisory panels for OTA studies guide OTA staff in

selecting issues and material to consider and in reviewing

the written work of the staff; however, such panels are not

responsible for the content of final reports. In 1988,

during the initial phase of the adolescent health project,

OTA developed a list of possible members for OTA’s

Adolescent Health Advisory Panel through searches of

relevant literature and discussions with researchers,

service providers, and other experts in adolescent health

issues. The 24 individuals who agreed to serve on OTA’s

Adolescent Health Advisory Panel came from a variety of

fields and had expertise in health policy, adolescent

development, mental health, social welfare, education,

adolescent medicine, nursing, psychology, and alcohol

and drug abuse policy and treatment (see listing at the

front of this volume). Many panel members were parents

of adolescents; in addition, the Parent-Teacher Association identified one person to be a parent representative.

Felton Earls, professor at the Harvard School of Public

Health chaired, and Michael Cohen, chairman of the

-1-127-
I-128 ● Adolescent Health-Volume I

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Box A-1--Full Table of Contents for OTA's Adolescent Health Report

VOLUME I: SUMMARY AND POLICY OPTIONS

Appendixes

A. Method of the study

B. Acknowledgments

C. Issues Related to the Lack of Information About Adolescent Health and Health and Related Services

D. Glossary of Abbreviations and Terms

VOLUME II: BACKGROUND AND THE EFFECTIVENESS OF SELECTED PREVENTION AND TREATMENT

SERVICES

1. Introduction

Part 1: Background on Adolescent Health

2. What Is Adolescent Health?

3. Parents’ and Families’ Influence on Adolescent Health

4. Schools and Discretionary Time

Part II: Prevention and Services Related to Selected Adolescent Health Concerns

prevention and Services Related to Physical Health Problems

5. Accidental Injuries: Prevention and Services

6. Chronic“ Physical Illesses: Prevention and Services

7. Nutrition and Fitness Problems: Prevention and Services

8. Dental and Oral Health Problems: Prevention and Services

Prevention and Services Related to Sexually Transmitted Diseases and Pregnancy

9. AIDS and Other Sexually Transmitted Disceases: Prevention and Services ●

10. Pregnancy and Parenting: Prevention and Services

Prevention and Services Related to Mental Health problem

11. Mental Health Problems: Prevention and services

12. Alcohol, Tobacco, and Drug Abuse: Prevention and Services

Prevention and Services Related to Delinquency and Homelessness

13. Delinquency: Prevention and Services

14. Homelessness: Prevention and Services

Appendix

A. Glosssary of Abbreviations and Terms

VOLUME HI: CROSSCUTTING ISSUES IN THE DELIVERY OF HEALTH AND RELATED SERVICES

15. Ma@ Issues Pertaining to the! Delivery of primary and comprehensive Health Services to Adolescents

16. Financial Access to Health Services

17. Consent and Confidentiality in Adolescent Health Care Decisionmaking

18. Issues in the Delivery of Services to Selected Groups of Adolescents

19. The Role of Federal Agencies in Adolescent Health

Appendixes

A. Glossary of Abbreviations and Terms

B. Burden of Health Problems Among U.S. Adolescents

C. HCFA’s Method for Estimatin“ g National Medicaid Enrollmoent and Expenditures for Adolescents

Department of Pediatrics at Montefiore Hospital, was to the panel members for their comments. In addition, the

vice-chair of the Advisory Panel.

The first meeting of the Adolescent Health Advisory

Panel was held on October 26, 1988. At that meeting, the

panel discussed the purpose of the study, the plan and

organization of the study, background materials, and key

issues to be included in the study. Preliminary drafts of the

entire report were reviewed by members of the Advisory

Panel and discussed at meetings of the panel members in

May 1989 and March 1990. Following these meetings,

OTA staff incorporated revisions and sent the new drafts

entire draft, each contributing contractor paper, and each

chapter were reviewed by the Advisory Panel and by

relevant outside experts. Taken together, more than 500

individuals reviewed aspects of the report (see app. B,

“Acknowledgments”). The final draft was sent to the

Technology Assessment Board in late July 1990,

Youth Advisory Panel

An unusual feature of OTA’s adolescent health assessment was that it included a Youth Advisory Panel to
Appendix A—Method of the Study ● 1-129

Box A-2—Requesters of OTA's Adolescent Health Report

(with current committee chair or ranking minority assignments)

Senator Daniel K. Inouye, Cha irman of the Senate Select Committee on Indian Affairs;

Senator Nancy Landon Kassebaum, Ranking Minority Member of the Subcommittee on Education, Arts, and Humanities of the

Senate Committee on Labor and Human Resources;

Senator Bob Dole, Minority Leader of the Senate;

Senator Robert C. Byrd, chairman of the Senate Committee on Appropriations;

Representative William H. Gray, III, Majority Whip of the House of Representatives;

Senator James M. Jeffords, Ranking Minority Member of the Subcommittee on Labor of the Senate Committee on Labor and

Human Resources;

Senator Orrin G. Hatch, Ranking Minority Member of the Senate Committee on Labor and Human Resources;

Senator Edward M. Kennedy, Chairman of the Senate Committee on Labor and Human Resources;

Senator Quentin W. Burdick, Chairman of the Senate Committee on Environment and Public Works;

Senator Mark O. Hatfield, Ranking Minority Member of the Senate Committee on Appropriations;

Senator Alan K. Simpson, Assistant Minority Leader of the Senate;

Senator Alan Cranston, chairman of the Senate Committee on Veterans Affairs;

Senator Ted Stevens, Rankin g Minority Member of the Senate Committee on Rules and Admini “ stration;

Senator Bob Packwood, Ranking Minority Member of the Senate Committee on Finance;

Senator Charles Grassley, Member of the Technology Assessment Board;

Senator Barbara Mikulski, Chairm an of the Subcommittee on Veterans Affairs, Housing and Urban Development, and

Independent Agencies of the Senate Committee on Appropriations;

Senator Ernest Hollings, Chairman of the Senate Committee on Commerce, Science, and Transportation;

Senator Arlen Specter, Ranking Minority Member of the Subcommittee on Veterans Affairs;

Representative Henry A. Waxman, Chairman of the Subcommittee on Health and the Environment of the House Committee on

Energy and Commerce;

Senator Daniel K. Akaka

Representative Morris K. Udall, Chairman of the House Committee on Interior and Insular Affairs;

Senator Frank H. Murkowski, Vice Chairman of the Senate Select Committee on Intelligence;

Senator Christopher. Dodd, Chairman of the Subcommittee on Children, Family, Drugs, and Alcohol of the Senate Committee

on Labor and Human Resources;

Senator Claiborne Pell$ Chairman of the Senate Committee on Foreign Relations;

Senator Dale Bumpers, Chairman of the Senate Committee on Small Business;

Senator Lloyd Bentsen, Chairman of the Senate Committee on Finance;

Senator Daniel P. Moynihan, Chairman of the Subcommittee on Social Security and Family Policy of the Senate Committee on

Finance;

Senator John D. Rockefeller, IV, Chairman of the Subcommittee on Medicare and Long Term Care of the Senate Committee

on Finance;

Representative Don Young, Ranking Minority Member of the House Committee on Interior and Insular Affairs.

A letter of support was received from the House Select Committee on Children, Youth, and Families.

provide OTA staff with an adolescent perspective on the Workshops

issues in the Report. The Youth Advisory Panel consisted

of 21 individuals who ranged in age from 10 to 19. Panel During the course of the study, OTA project staff

members represented a range of backgrounds: racial/ convened five workshops to discuss various issues

ethnic (white, non-Hispanic; Hispanic; Asian; black), relating to adolescent health. Three of these workshops

socioeconomic, and experiential (e.g., homeless, sub- (the second, third, and fifth workshops) were supported

stance use, pregnant, parenting, children of divorce, by the Carnegie Council on Adolescent Development.

children from stepfamilies, and extended families). Although all were from the greater Washington, DC, ●

metropolitan area, they came from central city, suburban,

and rural areas. During meetings, the Youth Advisory

Panel highlighted important health issues for adolescents,

developed a list of desirable features of health services, ●

and made recommendations to the project staff on ways

to improve adolescent health. Representatives of the

Youth Advisory Panel also attended various workshops

and meetings held by OTA. Members of OTA’s Youth

Advisory Panel are listed in box A-3.

The first workshop, on American Indian and Alaska

Native adolescents’ mental health, was held on

December 12-13, 1988, in Albuquerque, New Mexico.

The second workshop, on health service delivery to

adolescents, was held at OTA on August 1-2, 1989.

At this workshop, participants discussed the availability, access, effectiveness, and appropriateness of

various services for adolescents in such areas as

mental health, substance abuse, child welfare; in the
I-130 ● Adolescent Health—Volume I

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Photo credit: Office of Technology Assessment

An unusual feature of OTA’s adolescent health

assessment was the involvement of a panel of

10- to 19-year-olds who advised OTA.

mainstream health care system; and in alternative

organizational settings such as school-linked health

centers and free clinics. Workshop participants

responded to drafts prepared by OTA contractors.

In the third workshop, on the role of Federal agencies

in adolescent health, representatives from relevant

Federal departments and agencies discussed issues

relating to the nature and scope of the Federal role in

adolescent health. This workshop was held at OTA

on October, 11, 1989.

The fourth workshop, on socioeconomic and cultural/

ethnicity issues in the delivery of health services to

adolescents, was held on December 18-19, 1989, at

OTA. At this workshop, parties responded to first

drafts of papers prepared by OTA contractors.

On March 28, 1990, OTA held a final workshop to

discuss how various policy options of the Report

could incorporate an approach that was less focused

on health problems and more oriented to health

promotion.

Workshop attendees included adolescent health care

providers, academics, and adolescents. Participants of all

five of the workshops are listed at the end of this appendix.

Box A-3--Youth Advisory Panel for

OTA’s Adolescemt Health Report

Derrick Bames Sharon Knarvik

Washington, DC Washington, DC

Steven Bell Rachelle Lewis?

Burke, VA Washington, DC

Alex Ching Jonathan Polanin

Silver Spring, MD Greenbelt, MD

Steven Failer Bounhome Sayboune

Upper Marlboro, MD Hyattsvillc, MD

shiny Felix Rattana Sengsy

Washington, DC Hyattsville, MD

Vernonic Green Jennifer Smith

Washington, DC Suitland, MD

Sean Green Reagan Thomason Washington, DC Burke, VA

Lourdes Gutierrez Tulsa Williams

Washington, DC Washington, DC

Gregory Hunter Michael Wilson

Springfield, VA Roundhill, VA

Talynthia Jones

Washington, DC

Survey of Federal Agencies and Site Visits

In preparation for the workshop on the role of Federal

agencies, OTA staff conducted a survey of various

Federal agencies in August 1989 to determine the scope

and level of activity at the Federal level regarding

adolescent health. The results of the survey are presented

in chapter 19, “The Role of Federal Agencies in

Adolescent Health,” in Volume III.

In addition to conducting workshops and a survey of

Federal agencies, OTA staff made site visits, conducted

literature reviews, and performed other research activities. Project staff visited various programs in Los

Angeles, San Francisco, New Jersey, New York, Boston,

and Washington, DC, designed for adolescents. These

visits included school-linked health centers, communitybased adolescent health centers, hospital-based and health

maintenance organization-based adolescent clinics, youth

serving organizations, and various programs for special

groups, such as homeless adolescents and delinquents.

Contractor Papers

Thirty-one contractor papers were commissioned by

OTA during the course of the study on adolescent health
Appendix A—Method of the Study . /-131

and are listed below.1 The National Technical Information

Service (NTIS) in Springfield, VA, has copies of most of

the contractor papers; the NTIS classification numbers are

listed beside the specific contractor paper. For additional

information, call NTIS at (703) 487-4600.

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LaRue Allen, Ph. D., University of Maryland, and

Christina Mitchell, Ph. D., New York University,

Poverty and Adolescent Health* (NTIS No, PB

91-154 385/AS)

Trina Anglin, M. D., Ph. D., Cleveland Metropolitan

General Hospital, Health Service Delivery to Adolescents*

Lois Bergeisen, Gaithersburg, MD, Indian Adolescent Physical Health

Barbara Bums, Ph.D, Duke University, Carl A.

Taube, Ph.D, Johns Hopkins University, and John E.

Taube, University of Maryland, Mental Health

Services for Adolescents* (NTIS No. PB 91-154

344/AS)

Barbara Burns, Ph.D, Duke University, Carl A.

Taube, Ph.D, Johns Hopkins University, and John E.

Taube, University of Maryland, Use of Mental

Health Sector Services by Adolescents: 1975, 1980,

1986* (NTIS No. PB 91-154 344/AS)

Paul Casamassimo, D. D. S., M. S., Children’s Hospital, Columbus, OH, Adolescent Dental and Oral

Health (NTIS No. PB 91-154 336/AS)

Johanna Dwyer, D.Sc., R. D., New England Medical

Center Hospital, and CaroI N. Meredith, University

of California at Davis, Great Expectations.” Adolescent Nutrition and Fitness

James Emshoff, Ph.D. and Ronnie Margolin, Georgia State University, Treatment of Adolescent Substance Abuse: A National Review and Critique*

(NTIS No. PB 91-154 344/AS)

Mathea Falco, J. D., New York, NY, Primary Prevention of Alcohol, Tobacco, and Drug Use by

Adolescents

Ronald A, Feldman, Ph. D., Columbia University,

HOW Can Society Contribute to Meaningful Use of

Adolescents’ Spare Time? (NTIS No. PB 91-154

328/AS)

Michelle Fine, Ph. D., University of Pennsylvania,

Middle and Secondary School Environments as They

Affect Adolescent Well-Being (NTIS No. PB 91-154

328/AS)

James Garbarino, Ph. D., Erikson Institute, Adolescent Victims of Maltreatment (NTIS No. PB 91-154

310/AS)

Josephine Gittler, J. D., Mary Quigley-Rick, J. D.,

and Michael J. Saks, Ph. D., University of Iowa,

Adolescent Health Care Decisionmaking: The Law

and Public Policy* (available from Carnegie Coun-

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cil on Adolescent Development, Washington, DC

202/429-7979)

Angela Holder, LL.M., Yale University, Legal and

Ethical Issues Related to Adolescents’ Participation

in Research and Data Collection on Health and

Related Topics* (NTIS No. PB 91-154 377/AS)

Jonathan Klein, M. D., M. P. H., Milton Kotelchuck

Ph. D., and Gordon H. DeFriese, Ph. D., University of

North Carolina at Chapel Hill, Critical Evaluation of

Comprehensive Multi-Service Delivery Systems for

Adolescents: A Framework for Evaluation of Effectiveness and a Feasibility Analysis*

Barry Krisberg, Ph. D., National Council on Crime

and Delinquency, Juvenile Justice: A Critical Examination* (NTIS No. PB 91-154 351/AS)

Richard Kronick, San Diego, CA, Adolescent Health

Insurance Status: Analyses of Trends in Coverage

and Preliminary Estimates of the Effects of an

Employer Mandate and Medicaid Expansion on the

Uninsured (available from GPO (telephone number

202/783-3238); stock number 052-003-01 160-3)

Richard Kronick, San Diego, CA, Update: Adolescent Health Insurance Status* (NTIS No. PB 91-154

369/AS)

Spero Manson, Ph. D., University of Colorado,

Indian Adolescent Mental Health (available from

GPO (telephone number 202/783-3238); stock number 052-003-01 175-1)

Margaret McManus, Harriette Fox, Paul Newacheck,

Lori Wicks, and Rebecca Kelly, McManus Health

Policy, Inc., Medicaid Coverage of Adolescents

(NTIS No. PB 91-154 369/AS)

Gary B. Melton, Ph.D. and Lois B. Oberlander,

M. A., University of Nebraska-Lincoln, The Health

of Rural Adolescents (NTIS No. PB 91-154 385/AS)

Scott Menard, Ph. D., University of Colorado, The

Epidemiology of Minor Offending in Adolescence

(NTIS No. PB 91-154 351/AS)

Larry Mi’ike, M. D., J. D., University of Hawaii,

Health and Related Services for Native Hawaiian

Adolescents* (NTIS No. PB 91-154 385/AS)

Edward P. Mulvey, Ph. D., Michael A. Arthur, M. A.,

and N. Dickson Reppucci, Ph. D., University of

Pittsburgh, Review of Programs for the Prevention

and Treatment of Delinquency (NTIS No. PB 91-154

351/AS)

D. Wayne Osgood, Ph.D. and Janet K. Wilson,

University of Nebraska-Lincoln, Covariation Among

Health-Compromising Behaviors in Adolescence*

(NTIS No. PB 91-154 377/AS)

Carol Runyan, M. P. H., Ph. D., Elizabeth A. Gerken,

M. S. P. H., and Laura S. Sadowski, M.D., M. P. H.,

l~e ] b papers marked wi~ an asterisk are papers for which funding was provided by the Carnegie Corporation of New York and tie CaJnegie Council

on Adolescent Development.
1-132 ● Adolescent Health—Volume I

University of North Carolina, Unintentional Injury

Among Adolescents (NTIS No. PB 91-154 336/AS)

. Stanley Sue, Ph. D., University of California, Los

Angeles, and Nolan Zane, University of California at

Santa Barbara, Health and Related Services for

Asian American Adolescents* (NTIS No. PB 91-154

385/AS)

. Dalmas A. Taylor, Ph. D., Wayne State University,

and Phyllis A. Katz, Ph. D., Institute for Research on

Social Problems, Health and Related Services Available to Black Adolescents* (NTIS No. PB 91-154

385/AS)

● I-I. Rutherford Turnbull, Esq., J. D., LL.M., and Lisa

Dorrill, M. A., University of Kansas, Health Care

Services for Adolescents With Developmental Disabilities

. Robert Valdez, Ph. D., University of California, Los

Angeles, Factors Affecting Latino Adolescents’

Health and Health Care Use* (NTIS No. PB 91-154

385/AS )

. Margaret West, M.S. W., Ph.D. and Sally N. Stuart,

M. S. W., University of Washington, Child Welfare

Services for Adolescents* (NTIS No. PB 91-154

310/AS)

Participants in Workshops on Adolescent Health

Workshop #l—American Indian and Alaska Native Adolescents: Mental Health Problems and Services

Teresa LaFromboise, Chair

School of Education, Stanford University

Stanford, CA

Marva Benjamin

Minority Initiative Director

Child and Adolescent Service System Program

Technical Assistance Center

Georgetown University Child Development Center

Washington, DC

Irving Berlin

Professor

Division of Child and Adolescent Psychiatry

Department of Psychiatry

School of Medicine

University of Mexico

Albuquerque, NM

J.R. Cook

Executive Director

United National Indian Tribal Youth, Inc.

Oklahoma City, OK

Paul Dauphinais

School Psychologist

Turtle Mountain Community School

Bellcourt, ND

Kathryn Manness

Coordinator

American Indian program Development

Los Angeles, CA

Philip May

Assistant Professor

Department of Sociology

University of New Mexico

Albuquerque, NM

Henry Montes

program Officer

Health Promotion Program

Henry J. Kaiser Family Foundation

Menlo Park, CA

Leonard Saxe

Visiting Professor

Bigel Institute

Florence Heller School

Brandeis University

Waltham, MA

Judi Siegfried

Director

Service Center

Pueblo of Laguna

Old Laguna, NM

Norine Smith

Director

Indian Health Board

Minneapolis, MN

Evelyn Tucker

Anchorage, AK

Indian Health Service:

Albert Hiat

Chief

Children’s program

Indian Mental Health Branch

Indian Health Service

Albuquerque, NM
Appendix A—Method of the Study . /-133

Scott Nelson

Chief

Indian Mental Health Branch

Indian Health Service

Rockville, MD

Bureau of Indian Affairs:

Joe Little

Chief

Judicial Services

Bill Mehojah

Office of Indian Education

Congressional Staff:

Yvette Joseph

Professional Staff Member

Senate Select Committee on Indian Affairs

Authors of Contractor Papers:

Lois Bergeisen

Gaithersburg, MD

Spero Manson

Director

National Center for American Indian and Alaska Native

Mental Health Research

Gene Powers University of Colorado

Acting Director Health Sciences Center

Alcohol and Substance Abuse Office Denver, CO

Workshop #2—Adolescent Health Services Delivery

Robert Johnson, Chair

Associate Professor, Division of Adolescent Medicine

Department of Pediatrics, New Jersey Medical School

Newark, NJ

Nettie N. Baldwin

Counselor Specialist

Montgomery County Public Schools

Rockville, MD

Lenore Behar

Special Assistant for Child and Family Services

Division of Mental Health, Mental Retardation, and

Substance Abuse

Department of Human Resources

North Carolina Department of Human Resources

Raleigh, NC

Sheryl Brissett-Chapman

Associate Director of Clinical Services

Division of Child Protection

Children’s Hospital National Medical Center

Washington, DC

Michael I. Cohen

Chairman

Department of Pediatrics

Albert Einstein College of Medicine

Montefiore Medical Center

Bronx, NY

Delores L. Delaney

President

State of Virginia Parent-Teacher Association

Virginia Beach, VA

Arthur B. Elster

Director

Department of Adolescent Health

American Medical Association

Chicago, IL

Abigail English

Staff Attorney

National Center for Youth Law

San Francisco, CA

Beverly Farquhar

Executive Director

National Association of School Nurses

Scarborough, ME

Julia Glover

Assistant Director

The Door

New York, NY

Vince Hutchins

Director, Office of Maternal and Child Health

Bureau of Maternal and Child Health and Resources

Development

Health Resources and Services Administration

U.S. Department of Health and Human Resources

Rockville, MD

Paul Jellinek

Senior Program Officer

Robert Wood Johnson Foundation

Princeton, NJ
I-134 . Adolescent Health—Volume I

Renee Jenkins

Director

Division of Adolescent Medicine

Howard University School of Medicine

Washington, DC

I-m-mine Klerman

Professor

Department of Epidemiology and Public Health

Yake University

New Haven, CT

Julia Graham Lear

Co-Director

The School-Based Adolescent Health Care Program

Children”s Hospital National Medical Center

Washington, DC

Mary Nell Lehnhard

Vice President

Office of Government Relations

Blue Cross and Blue Shield Association

Washington, DC

Ira Lourie

Director

Child and Adolescent Service System Program

National Institute of Mental Health

U.S. Department of Health and Human Services

Rockville, MD

Barbara D. Matula

Director

Division of Medical Assistance

Department of Human Resources

State of North Carolina

Raleigh, NC

Robert B. Millman

Director

Adolescent Development Program

Director

Alcohol and Substance Abuse Service

Cornell University Medical College

New York NY

Elena O. Nightingale

Special Advisor to the President

Senior Advisor to the Carnegie Council on

Adolescent Development

Carnegie Corporation of New York

Washington, DC

Lee Etta Powell

Superintendent

Cincinnati Public Schools

Cincinnati, OH

Elizabeth Rahdert

Research Psychologist

Treatment Research Branch

Division of Clinical Research

National Institute on Drug Abuse

U.S. Department of Health and Human Services

Rockville, MD

Michael D. Resnick

Professor

Adolescent Health Program

Department of Pediatrics

University of Minnesota

Minneapolis, MN

Julius B. Richmond

Professor Emeritus

Division of Health Policy Research and Education

Harvard University

Boston, MA

Joe M. Sanders, Jr.

Associate Executive Director

American Academy of Pediatrics

Elk Grove Village, IL

Edward Tetelman

Assistant Commissioner

Intergovernmental Affairs

New Jersey Department of Human Services

Trenton, NJ

Gary Yates

Director

High Risk Youth Program

Division of Adolescent Medicine

Children’s Hospital

Los Angeles, CA

Youth Advisors:

Angela Baldwin

Alex Ching

Sharon Knarvik

Authors of Contractor Papers:

Trina Anglin

Chief

Adolescent Medicine

Department of Pediatrics

Cleveland Metropolitan General Hospital

Cleveland, OH

Barbara Bums

Professor of Medical Psychology

Duke University Medical Center

Durham, NC
Appendix A—Method of the Study .1-135

James Emshoff

Associate Professor

Department of Psychology

Georgia State University

Atlanta, GA

Josephine Gittler

Professor

National Maternal and Child Health Resource Center

College of Law

University of Iowa

Iowa City, IA

D. Wayne Osgood

Assistant Professor

Department of Sociology

University of Nebraska-Lincoln

Lincoln, NE

Michael Saks

Professor

College of Law

University of Iowa

Iowa City, IA

Margaret West

Co-Director

National Resource Institute on Children

and Youth With Disabilities

University of Washington

Seattle, WA

Mary Quigley-Rick

Associate Director

National Maternal and Child Health Resource Center

College of Law

University of Iowa

Iowa City, IA

Workshop #3—The Federal Role in Adolescent Health

Felton Earls, Chair

Professor, Department of Behavioral Sciences

Harvard School of Public Health

Boston, MA

Michael I. Cohen, Vice Chair

Chairman, Department of Pediatrics

Albert Einstein College of Medicine, Montefiore Medical Center

Bronx, NY

Richard Abell

Assistant Attorney General

Office of Justice Programs

U.S. Department of Justice

Washington, DC

Edgar Adams

Director

Division of Epidemiology and Prevention Services

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Barbara Allen-Hagen

Social Sciences Analyst

Office of Juvenile Justice and Delinquency Prevention

U.S. Department of Justice

Washington, DC

Katherine Armstrong

Office of Disease Prevention and Health Promotion

U.S. Department of Health and Human Services

Washington, DC

Wendy Baldwin

Chief

Demographic and Behavioral Sciences Branch

National Institute of Child Health and

Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Delores Battel

Administrator

Office of Job Training Programs

U.S. Department of Labor

Washington, DC
1-136 ● Adolescent Health—Volume I

Carol Behrer

Associate Commissioner

Family and Youth Services Bureau

Office of Human Development Services

U.S. Department of Health and Human Services

Washington, DC

George Brenneman

Maternal and Child Health Coordinator

Indian Health Service

U.S. Department of Health and Human Services

Rockville, MD

Christine Brown

Coordinator

Child Abuse/Neglect/Sexual Abuse

Bureau of Indian Affairs

U.S. Department of the Interior

Washington, DC

Leslie Christovich

Program Analyst

Office of Analysis and Evaluation

U.S. Department of Agriculture

Alexandria, VA

Dorinne Czechowicz

Associate Director

Medical and Professional Affairs

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Ellen Daley

Program Analyst

Budget Planning and Policy

National Highway Traffic Safety Administration

U.S. Department of Transportation

Washington, DC

Sigmund Dragastin

Acting Chief

Child and Adolescent Disorders Research Branch

Division of Clinical Research

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

William Drummond

Special Assistant

Office of the Assistant Secretary

Office of Elementary and Secondary Education

U.S. Department of Education

Washington, DC

Lou Enoff

Deputy Director

Social Security Administration

U.S. Department of Health and Human Services

Baltimore. MD

Karen Faison

Rehabilitation program Specialist

National Institute of Disability and Rehabilitation

Research

Office of Special Education and Rehabilitative Services

U.S. Department of Education

Washington, DC

William Fitzgerald

program Analyst

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Arthur S. Funke

Chief Psychologist

Office of Maternal and Child Health

Bureau of Maternal and Child Health and Resources

Development

US. Department of Health and Human Services

Rockville, MD

Joel Gamer

Special Assistant to the Assistant Inspector for the Office

of Crime Prevention and Criminal Justice Research

U.S. Department of Justice

Washington, DC

Jacob Gayle

Special Assistant for Minority HIV Policy

Centers for Disease Control

Public Health Service

U.S. Department of Health and Human Services

Atlanta, GA

Joann Gephart

Nurse Consultant

Bureau of Maternal and Child Health and Resources

Development

U.S. Department of Health and Human Services

Rockville, MD

Gilman Grave

Chief

Endocrinology and Nutrition Growth Branch

National Institute of Child Health and Human

Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Antoinette Hagey

Senior Policy Analyst

U.S. Department of Defense

Washington, DC
Appendix A—Method of the Study . /-137

Howard Hanna

Chief

Director of Program Development

Office of Highway Safety

Federal Highway Administration

U.S. Department of Transportation

Washington, DC

Margaret Heagney

Special Assistant to the Director

Office of Program and Planning Legislation

U.S. Department of Health and Human Services

Washington, DC

Janyce Hedetniemi

Chief

Planning and Coordination Branch

National Heart, Lung, and Blood Institute

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Janet Heinrich

Director

Division of Extramural Programs

National Center for Nursing Research

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Gerry Hendershot

Chief

Illness and Disabilities Statistics

Division of Health Interview Statistics

National Center for Health Statistics

U.S. Department of Health and Human Services

Hyattsville, MD

James G. Hill

Chief

Office of Planning and Evaluation

National Institute of Child Health and Human

Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Alan Hinman

Center for Prevention Services

Centers for Disease Control

Public Health Service

U.S. Department of Health and Human Services

Atlanta, GA

William Hiscock

Chief

Financial Policy Branch

Health Care Financing Administration

U.S. Department of Health and Human Services

Woodlawn, MD

Lea Hoopfer

Deputy Administrator

4H and Youth Programs

U.S. Department of Agriculture

Washington, DC

Marc Horowitz

Program Analyst

Office of AIDS Research

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Dawn Hunter

Acting Branch Chief

Program Review Branch

Office of Special Education and Rehabilitative Services

U.S. Department of Education

Washington, DC

Vince Hutchins

Director

Office of Maternal and Child Health

Bureau of Maternal and Child Health and Resources

Development

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, MD

Richard Jakopic

Social Science Research Analyst

Office of Program and Planning Legislation

U.S. Department of Health and Human Services

Washington, DC

Elaine Johnson

Director

Office of Substance Abuse Prevention

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Lloyd Kolbe

Director

Division of Adolescent and School Health

Center for Chronic Disease Prevention and

Health Promotion

Centers for Disease Control

Public Health Service

U.S. Department of Health and Human Services

Atlanta. GA
I-138 ● Adolescent Health—Volume I

Norman Krasnegor

Chief

Human Learning and Behavior Branch

Center for Research for Mothers and Children

National Institute of Child Health and Human

Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Judy Lewis

Office of the Assistant Secretary

Office of Postsecondary Education

U.S. Department of Education

Washington, DC

G.M. Nana Lopez

Chief Dentist

Primary Care Services Division

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, MD

Paul T. McDavid

Director

Office of the Civilian Health and Medical

Program of the Uniformed Services

U.S. Department of Defense

Aurora, CO

Patricia McNeil

Administrator

Office of Strategic Planning and Development

U.S. Department of Labor

Washington, DC

Bill Mehojah

Branch Chief

Office of Elementary and Secondary Education

Bureau of Indian Affairs

U.S. Department of the Interior

Washington, DC

James A. Mercy

Assistant Director for Science

Division of Injury Epidemiology and Control

Center for Environmental Health and Injury Control

Centers for Disease Control

Public Health Service

U.S. Department of Health and Human Services

Atlanta, GA

Roberta Miller

Directorate for Biological, Behavioral, and Social

Sciences

National Science Foundation

Washington, DC

Susan Newcomer

Expert

Demographic and Behavioral Sciences Branch

National Institute of Child Health and Human

Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Carol Pollack-Nelson

Human Factors Specialist

U.S. Consumer Product Safety Commission

Bethesda, MD

Larry Radbill

Statistician, Population Division

Bureau of the Census

U.S. Department of Commerce

Washington, DC

Elizabeth Rahdert

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Claude Reeder

Deputy Director

Office of Policy Analysis

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Howard Riddick

Food and Consumption Branch

Nutrition Monitoring Division

Human Nutrition Information Service

U.S. Department of Agriculture

Hyattsville, MD

Patricia Salomon

Chief Medical Officer

Special Populations Program Development Division

Bureau of Health Care Delivery and Assistance

U.S. Department of Health and Human Services

Rockville, MD

Nancy Saltford

Deputy Administrator

Home Economics and Nutrition

U.S. Department of Agriculture

Washington, DC

Robert Scholle

Policy Analyst

Office of Population Affairs

Public Health Service

U.S. Department of Health and Human Services

Washington, DC
Appendix A—Method of the Study . I-139

Ann Segal

Director

Division of Children, Youth, and Family Policy

U.S. Department of Health and Human Services

Washington, DC

Linda K. Smith

Force Management and Personnel

U.S. Department of Defense

Washington, DC

Diane Sondheimer

Epidemiologist

Pediatric, Adolescent, and Maternal AIDS Branch

National Institute of Child Health and Human

Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Sandra Spaulding

Director

Planning and Support Division

Administration for Native Americans

Office of Human Development Services

U.S. Department of Health and Human Services

Washington, DC

Elaine Stone

Health Scientist Administrator

Preventive Cardiology Branch

National Heart, Lung, and Blood Institute

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Barry Sweedler

Director

Bureau of Safety Programs

National Transportation Safety Board

Washington, DC

Jane Taylor

Director

Children, Adolescent, and Youth programs

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Maria Vegega

Researcher

Office of Driver and Pedestrian Research

National Highway Traffic Safety Administration

U.S. Department of Transportation

Washington, DC

Cathy J. Wasem

Program Analyst, Rural Health

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, MD

Rita Weiss

Highway Safety Specialist

Office of Occupant Protection

National Highway Traffic Safety Administration

U.S. Department of Transportation

Washington, DC

Anne Willoughby

Chief

Pediatric, Adolescent, and Maternal AIDS Branch

Center for Research for Mothers and Children

National Institute of Child Health and Human

Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD
I-140 Adolescent Health—Volume I

Workshop #4—Socioeconomic and Cultural/Ethnicity Issues in the Delivery of

Health Services to Adolescents

Michael I. Cohen, Chair

Chairman, Department of Pediatrics

Albert Einstein College of Medicine

Montefiore Medical Center

Bronx, NY

Michael Graf

Fairbanks, AK

Robert Johnson

Associate Professor

Division of Adolescent Medicine

Department of Pediatrics

New Jersey Medical School

Newark, NJ

Teresa LaFromboise

Assistant Professor

School of Education

Stanford University

Stanford, CA

Christina Mitchell

Senior Research Scientist

Center for Community Research and Action

New York University

New York City, NY

Leticia Paez

Associate Director

Area Health Education Center

School of Medicine

Texas Technical University

El Paso, TX

Lee Etta Powell

Superintendent

Cincinnati Public Schools

Cincinnati, OH

Roxanne Spillett

Director, Program Services

Boys and Girls Clubs of America

New York NY

Myron Thompson

Trustee

Bernice Pauahi Bishop Estate

Honolulu, HI

Youth Advisors:

Derrick Barnes

Alex Ching

Sharon Knarvik

Jennifer Smith

Authors of Contractor Papers:

LaRue Allen

Professor

Department of Psychology

University of Maryland

College Park, MD

Lois Bergeisen

Consultant

Gaithersburg, MD

Phyllis Katz

Director

Institute for Research on Social Problems

Boulder, CO

Larry Mi’ike

Professor of Medical Policy

John A. Burns School of Medicine

University of Hawaii at Manoa

Honolulu, HI

Marjorie Kagawa Singer

Professor

UCLA School of Nursing

Los Angeles, CA

Dalmas Taylor

College of Liberal Arts

Wayne State University

Detroit, MI
Appendix A—Method of the Study . /-141

Michael I. Cohen

Chairman

Department of Pediatrics

Albert Einstein College of Medicine

Montefiore Medical Center

Bronx. NY

Bruce E. Compas

Santa Monica, CA

on sabatical from

Department of Psychology

University of Vermont

Burlington, VT

Thomas D. Cook

Center for Urban Affairs

Northwestern University

Evanston. IL

Felton Earls

Professor

Department of Behavioral Sciences

Harvard School of Public Health

Boston, MA

Workshop #5—Health Promotion

Arthur B. Elster

Director

Department of Adolescent Health

American Medical Association

Chicago, IL

Judith Igoe

Director

School Health Program

University of Colorado

Denver, CO

Susan G. Millstein

Professor

Division of Adolescent Medicine

University of California

San Francisco. CA

Anne C. Petersen

Dean

College of Health and Human Development

Pennsylvania State University

University Park PA
Appendix B

ACKNOWLEDGMENTS

OTA would like to express its appreciation for the assistance of the Adolescent Health Advisory Panel (see front matter), the

Youth Advisory Panel, workshop participants, and contractors (see app. A). OTA would also like to thank the following individuals

and organizations that reviewed drafts, provided information, or otherwise contributed to this assessment. These individuals and

organizations do not necessarily approve, disapprove, or endorse this Report. OTA assumes full responsibility for the Report and the

accuracy of its contents.

Richard Abell

Office of Justice Programs

U.S. Department of Justice

Washington, DC

Edgar Adams

Division of Epidemiology and Prevention Services

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Carl Akins

Office of the Civilian Health and Medical Program of the

Uniformed Services

U.S. Department of Defense

Aurora, CO

Duane Alexander

National Institute of Child Health and Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

James R. Allen

Office of the Assistant Secretary for Health

U.S. Department of Health and Human Services

Washington, DC

Barbara Allen-Hagen

Office of Juvenile Justice and Delinquency Prevention

U.S. Department of Justice

Washington, DC

John Ambrose

National Mental Health Association

Alexandria, VA

American Civil Liberties Union

New York, NY

John Andelin

Office of Technology Assessment

U.S. Congress

Washington, DC

Judy A. Andrews

Oregon Research institute

Eugene, OR

Katherine Armstrong

Healthy People Programs

Western Consortium for Public Health

Berkeley, CA

Rudy Arredondo

Office of Latino Affairs

D,C. Public Health Commission

Washington, DC

Kent Augustson

Office of Substance Abuse Prevention

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Jerald G. Bachman

University of Michigan

Ann Arbor, MI

Christine A. Bachrach

National Institute of Child Health and Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Susan P. Baker

Johns Hopkins University

Baltimore, MD

Wendy Baldwin

National Institute of Child Health and Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Vikki Balet

Children of the Night

Los Angeles, CA

Helen S. Banta

National Commission on Correctional Health Care

Chicago, IL

Frankie Barnes

Center for Prevention Services

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

William Barrett

ACTION

Washington, DC

Ellen Bassuk

The Better Homes Foundation

Newton Centre, MA

-I-142-
.

Appendix B-Acknowledgments . /-143

Delores Battle

Office of Job Training Programs

U.S. Department of Labor

Washington, DC

Diana Baumrind

Institute of Human Development

University of California, Berkeley

Berkeley, CA

Katherine Beckman

Carnegie Council on Adolescent Development

Washington, DC

Carol Behrer

Office of Human Development Services

U.S. Department of Health and Human Services

Washington, DC

Marva Benjamin

Child and Adolescent Service System Program

Technical Assistance Center

Georgetown University

Washington, DC

Janice Berger

Office of Treatment Improvement

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Catherine A. Bertini

Office of the Secretary

U.S. Department of Agriculture

Washington, DC

Robert W. Blum

Adolescent Health Program

University of Minnesota

Minneapolis, MN

Dale Blyth

Department of Adolescent Health

American Medical Association

Chicago, IL

Daniel Bonner

U.S. Department of Education

Washington, DC

Patricia Bowden

Howard University School of Medicine

Washington, DC

Tracy Brandt

National Academy of Sciences

Washington, DC

Mary Brecht-Carpenter

National Commission To Prevent Infant Mortality

Washington, DC

Jim Breiling

Antisocial and Violent Behavior Branch

National Institute of Mental Health

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Jerald Breitman

Burroughs Wellcome Co.

Research Triangle Park, NC

George Brenneman

Indian Health Service

U.S. Department of Health and Human Services

Rockville, MD

Nan Broadbent

Burness Communications

Bethesda, MD

Jean Brooks-Gunn

Educational Testing Service

Princeton, NJ

Bernard Brown

Administration for Children, Youth, and Families

Office of Human Development Services

U.S. Department of Health and Human Services

Washington, DC

Christine Brown

Bureau of Indian Affairs

U.S. Department of the Interior

Washington, DC

Gloria Primm Brown

Carnegie Corporation of New York

New York, NY

Ann Brunswick

Columbia University

New York, NY

William Bukoski

National Institute on Drug Abuse

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

David Bunoski

Office of Human Development Services

U.S. Department of Health and Human Services

Washington, DC

Robert Burininks

University of Minnesota

Minneapolis, MN

John Burnett

Office of Technology Assessment

U.S. Congress

Washington, DC

William M. Buzogany

Child-Adolescent Program

Mendota Mental Health Institute

Madison, Wl
!-144 ● Adolescent Health—Volume I

Timothy S. Bynum

School of Criminal Justice

Michigan State University

East Lansing, MI

Lawrence Cabus

Child Development Department

Special Services for Groups

Lawndale, CA

Robert A. Caldwell

Michigan State University

East Lansing, MI

John A. Calhoun

National Crime Prevention Council

Washington, DC

Jack Carrel

The Los Angeles Free Clinic

Los Angeles, CA

Betty Ruth Carruth

Department of Nutrition and Food Sciences

College of Human Ecology

University of Tennessee

Knoxville, TN

Nancy Carson

Office of Technology Assessment

U.S. Congress

Washington, DC

Edna Carter

Office of Elementary and Secondary Education

U.S. Department of Education

Washington, DC

Carl J. Caspersen

Center for Chronic Disease Prevention and

Health Promotion

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Willard Cates, Jr.

Center for Prevention Services

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Ann Chadwick

Office of the Assistant Secretary for

Food and Consumer Services

U.S. Department of Agriculture

Hyattsville, MD

Janet Chapin

Division of Program Services

American College of Obstetrics and Gynecology

Washington, DC

Leslie Christovich

Office of Analysis and Evaluation

U.S. Department of Agriculture

Alexandria, VA

Joseph Cislowski

National Commission on Children

Washington, DC

Fern Clark

Office of Hawaiian Health

Hawaii Department of Health

Honolulu, HI

Anne H. Cohn

National Committee for the Prevention of Child Abuse

Chicago, IL

Beth Collins

Center for Chronic Disease Prevention

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Julia Connally

Office of Technology Assessment

U.S. Congress

Washington, DC

Liz Conway

Blue Cross and Blue Shield Association

Washington, DC

Lynne H. Cook

Officce of Special Education Programs

U.S. Department of Education

Washington, DC

Mark Covall

National Association of Private Psychiatric Hospitals

Washington, DC

Mary Crosby

American Academy of Child and Adolescent Psychiatry

Washington, DC

Larry Culpepper

Department of Family Medicine

Memorial Hospital of Rhode Island

Pawtucket, RI

James Curran

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Dorynne Czechowicz

National Institute on Drug Abuse

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Judy Dailey

American Dietetic Association

Chicago, IL

Ellen Daley

Budget Planning and Policy

National Highway Tra.file Safety Administration

U.S. Department of Transportation

Washington, DC
Appendix B-Acknowledgments . /-145

Michael G. Dana

Office of Planning, Budget, and Evaluation

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Williams S. Davidson II

Michigan State University

East Lansing, MI

Robert R. DaviIla

Office of Special Education and Rehabilitative Services

U.S. Department of Education

Washington, DC

Dana A. Davis

American School Health Association

Kent, OH

Christopher DeGraw

Office of Disease Prevention and Health Promotion

U.S. Department of Health and Human Services

Washington, DC

Denny De Gross

Alaska Native Health Board

Anchorage, AK

Mark Desetell

Congressional Budget Office

U.S. Congress

Washington, DC

Christine Dewhurst

Juvenile Justice Clearinghouse

Aspen Systems Corp.

Rockville, MD

Jose Manuel de la Rosa

Texas Tech University

El Paso, TX

Ralph DiClemente

Department of Epidemiology and International Health

University of California, San Francisco

San Francisco, CA

Sam DiMenza

Office of Treatment Improvement

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Terrence Donahue

Office of Juvenile Justice and Delinquency Prevention

U.S. Department of Justice

Washington, DC

Ann Downer

University of Washington

Seattle, WA

Sigmund Dragastin

National Institute of Mental Health

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

D. Peter Drotman

Center for Infectious Diseases

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

William Drummond

Office of the Assistant Secretary for Elementary and

Secondary Education

U.S. Department of Education

Washington, DC

Joy G. Dryfoos

Hastings on Hudson, NY

Howard Dubowitz

University of Maryland Medical School

Baltimore, MD

Linda Dusenbury

The New York HospitalCornell Medical Center

New York, NY

Annette Dyer

Carnegie Council on Adolescent Development

Washington, DC

Craig Edelbrock

University of Massachusetts Medical Center

University of Massachusetts

Worcester, MA

Delbert S. Elliott

Behavioral Research Institute

Boulder, CO

Glen R. Elliott

Langley Porter Psychiatric Institute

University of California, San Francisco

San Francisco, CA

Arthur Elster

Department of Adolescent Health

American Medical Association

Chicago, IL

Lou Enoff

Social Security Administration

U.S. Department of Health and Human Services

Baltimore, MD

Judith B. Erickson

Indian Youth Institute

Indianapolis, IN

Barbara Faigan

National Highway Traffic SafetyAdmini stration

U.S. Department of Transportation

Washington, DC

Karen Faison

Office of Special Education and Rehabilitative Services

U.S. Department of Education

Washington, DC

Kenneth Farley

Washington, DC
i-146 ● Adolescent Health—Volume I

Donna Farrar

Council on Exceptional Children

Reston, VA

David P. Barrington

Institute of Criminology

Cambridge University

Cambridge, England

Manning Feinleib

National Center for Health Statistics

Centers for Disease Control

U.S. Department of Health and Human Services

Hyattsville, MD

Carolyn Feis

General Accounting Office

U.S. Congress

Washington, DC

Barbara Finberg

Carnegie Corporation of New York

New York, NY

Baruch Fischhoff

Department of Social and Decision Sciences

Carnegie Mellon University

Pittsburgh, PA

Michael Fishman

Bureau of Maternal and Child Health

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, MD

William Fitzgerald

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Brian R. Flay

Prevention Research Center

University of Illinois at Chicago

Chicago, IL

Katherine Flegal

National Center for Health Statistics

Centers for Disease Control

U.S. Department of Health and Human Services

Hyattsville, MD

Robert G. Frank

Department of Physical Medicine and Rehabilitation

University of Missouri-Columbia

Columbia, MO

Herbert L. Friedman

Maternal and Child Health

World Health Organization

Geneva, Switzerland

Robert Friedman

Research and Training Center for Improved Services for

Seriously Emotionally Disturbed Children

Florida Mental Health Institute

University of South Florida

Tampa, FL

Lisa Fries

Hermosa Beach, CA

Arthur S. Funke

Bureau of Maternal and Child Health

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, MD

Frank Furstenberg

University of Pennsylvania

Philadelphia, PA

Mary Sheila Gall

Office of Human Development Services

U.S. Department of Health and Human Services

Washington, DC

Susan Gallagher

Education Development Center

Newton, MA

Barry D. Garfinkel

University of Minnesota

Minneapolis, MN

Joel Garner

U.S. Department of Justice

Washington, DC

Jacob A. Gayle

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Virginia Geoffrey

Arlington, VA

Joanne Gephart

Bureau of Maternal and Child Health

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, MD

Suzanne Giraudo

Pacific Presbyterian Medical Center

San Francisco, CA

Thomas J. Gleaton

PRIDE

Atlanta, GA

Julie Glover

The Door

New York, NY

Marsha Gold

Group Health Association of America

Washington, DC

Jackie Goldberg

Los Angeles City Board of Education

Los Angeles, CA
Appendix B-Acknowledgments .1-147

Margaret Gooch

Bureau of Health Care Delivery and Assistance

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, MD

Laurie Goodman

Kaiser Permanente Teen and Young Adult Health Center

Granada Hills, CA

Eric Goplerud

Office of National Drug Control Policy

Executive Office of the President

Washington, DC

Steven L. Gortmaker

Department of Behavioral Sciences

Harvard School of Public Health

Boston, MA

Denise Gottfredson

John Hopkins University

Baltimore, MD

John Graham

Harvard School of Public Health

Boston, MA

Gilman Grave

National Institute of Child Health and Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Peter Greenwood

Criminal Justice Program

The Rand Corp.

Santa Monica, CA

Thomas Grisso

University of Massachusetts Medical Center

Worcester, MA

Shirley A. Gross

Bayview Hunters Point Foundation

San Francisco, CA

Tessie Guillermo

Asian American Health Forum

San Francisco, CA

Antoinette Hagey

U.S. Department of Defense

Washington, DC

Robert Haggerty

William T. Grant Foundation

New York, NY

Samuel Halperin

Youth and America’s Future: Commission on Work,

Family, and Citizenship

William T. Grant Foundation

Washington, DC

Beatrix A. Hamburg

Mount Sinai Medical Center

New York, NY

Donna Hamparian

The Ohio Serious Juvenile Offender Project

Federation for Community Planning

Cleveland, OH

Jerome H. Hanley

Special Division of Children’s Services

South Carolina Department of Mental Health

Columbia, SC

Howard Hanna

Office of Highway Safety

Federal Highway Administration

U.S. Department of Transportation

Washington, DC

Evi Hatziandreu

Office of Technology Assessment

U.S. Congress

Washington, DC

J. David Hawkins

School of Social Work

University of Washington

Seattle, WA

Betty L. Hawks

Office of Minority Health

Office of the Assistant Secretary for Health

U.S. Department of Health and Human Services

Washington, DC

Richard W. Hays

Drug Abuse Prevention Oversight Staff

U.S. Department of Education

Washington, DC

Louis Hays

Health Care Financing Administration

U.S. Department of Health and Human Services

Washington, DC

Margaret Heagney

Office of Human Development Services

U.S. Department of Health and Human Services

Washington, DC

Felix P. Heald

University of Maryland

Baltimore, MD

Janyce Hedetniemi

National Heart, Lung, and Blood Institute

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Janet Heinrich

National Center for Nursing Research

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Ray E. Heifer

Michigan State University

East Lansing, MI
I-148 ● Adolescent Health—Volume I

Gerry Hendershot

National Center for Health Statistics

Centers for Disease Control

U.S. Department of Health and Human Services

Hyattsville, MD

Robert L. Hendren

Division of Child and Adolescent Psychiatry

Department of Psychiatry

School of Medicine Mental Health Programs

The University of New Mexico

Albuquerque, NM

Stanley Henshaw

Alan Guttmacher Institute

New York, NY

David Heppel

Bureau of Maternal and Child Health

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, MD

Jeanne Hernandez

University of North Carolina at Chapel Hill

Chapel Hill, NC

Warren Hewitt

Office of Treatment Improvement

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

David Hickman

National Institute of Mental Health

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

James G. Hill

National Institute of Child Health and Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Alan Hinman

Center for Prevention Services

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

William Hiscock

Health Care Financing Administration

U.S. Department of Health and Human Services

Baltimore, MD

Sandra Hofferth

Urban Institute

Washington, DC

Adele D. Hoffmann

Children’s Hospital of Orange County

Orange, CA

Patrick Hogan

U.S. Department of Education

Washington, DC

Lea Hoopfer

4H and Youth Programs

U.S. Department of Agriculture

Washington, DC

Marc Horowitz

Office of AIDS Research

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Charlotte Horton

Washington, DC

Rebecca Horton

Washington, DC

Angela Holder

Yale University School of Medicine

New Haven, CT

King K. Holmes

University of Washington

Harbor View Medical Center

Department of Medicine

Seattle, WA

Helen Howerton

Off& of Human Development Services

U.S. Department of Health and Human Services

Washington, DC

Vince L. Hutchins

Bureau of Maternal and Child Health

Health Resources and Services Admini stration

U.S. Department of Health and Human Services

Rockville, MD

Jean Hyche-Williams

Center for Population Options

Washington, DC

Jon E. Irby

Extension Service

U.S. Department of Agriculture

Washington, DC

Richard Jakopic

Office of Program and Planning Legislation

U.S. Department of Health and Human Services

Washington, DC

Paul Jellinek

Robert Wood Johnson Foundation

Princeton, NJ

Renee Jenkins

Division of Adolescent Medicine

Howard University School of Medicine

Washington, DC

Peter S. Jensen

National Institute of Mental Health

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD
Appendix B-Acknowledgments . 1-149

Richard Jessor

University of Colorado at Boulder

Boulder, CO

Dion Johnson

Washington, DC

Elaine Johnson

Office of Substance Abuse Prevention

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Kay Johnson

Children’s Defense Fund

Washington, DC

Craig Vincent Jones

South Bay Free Clinic

Manhattan Beach, CA

Jack Jones

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Robert T. Jones

Assistant Secretary for Employment and Training

U.S. Department of Labor

Washington, DC

Cynthia M. Jorgensen

National AIDS Information and Education Program

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Diane C. Jest

Blue Cross and Blue Shield Association

Washington, DC

Lewis Judd

National Institute of Mental Health

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Laura Kahn

Division of Adolescent and School Health

Center for Chronic Disease Prevention and Health Promotion

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Lisa Kaiser

Alan Guttmacher Institute

Washington, DC

Denise Kandel

Columbia University

New York, NY

George Kanuck

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Martha Katz

Office of Program Planning and Evaluation

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Charles J. Kehoe

Department of Youth Services

Commonwealth of Virginia

Richmond, VA

Kelly Kelleher

National Institute of Mental Health

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Terry Kelly

Native Hawaiian Drug Free Schools/Communities

Program

Honolulu, HI

John H. Kelso

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, MD

Jane A. Kenny

ACTION

Washington, DC

Woodie Kessel

Bureau of Maternal and Child Health

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, MD

Charles Kinderman

Bureau of Justice Statistics

U.S. Department of Justice

Washington, DC

Allen King

U.S. Department of Education

Washington, DC

Dawn Hunter King

Office of Special Education and Rehabilitative Services

U.S. Department of Education

Washington, DC

Douglas Kirby

ETR Associates

Santa Cruz, CA

Edward Klebe

Education and Public Welfare Division

Congressional Research Service

U.S. Congress

Washington, DC

Jonathan D. Klein

University of North Carolina at Chapel Hill

Chapel Hill, NC
I-150 ● Adolescent Health--Volume I

Malcolm Klein

Department of Sociology

University of Southern California

Los Angeles, CA

John Klemm

Division of Medical Cost Estimates

Office of the Actuary

Health Care Financing Administration

U.S. Department of Health and Human Services

Baltimore, MD

Sue Kline

Corrections Unit

Bureau of Justice Statistics

U.S. Department of Justice

Washington, DC

Irving N. Klitzner

Kaiser Permanence Teen and Young Adult Health Center

Granada Hills, CA

Michael Klitzner

Pacific Institute for Research and Evaluation

Bethesda, MD

Sharon Knarvik

Washington, DC

Jane Knitzer

Division of Research

Bank Street College of Education

New York, NY

Roberta Knowlton

New Jersey Department of Human Services

Trenton, NJ

Bob Kohmescher

Division of STD/HIV Prevention

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Charles Kolb

U.S. Department of Education

Washington, DC

Lloyd Kolbe

Division of Adolescent and School Health

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Elaine Kolodny

Employment and Training Administration

U.S. Department of Labor

Washington, DC

James Kolstad

National Transportation Safety Board

Washington, DC

Gary Kovalczyk

Office of Management and Budget

ACTION

Washington, DC

Mary Grace Kovar

Office of Vital and Health Statistics Systems

National Center for Health Statistics

Centers for Disease Control

U.S. Department of Health and Human Services

Hyattsville, MD

Chris Koyanagi

National Mental Health Association

Alexandria, VA

Norman Krasnegor

National Institute of Child Health and Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Jess F. Kraus

University of California, Los Angeles

Los Angeles, CA

Barry Krisberg

National Council on Crime and Delinquency

San Francisco, CA

Fred Kroger

National AIDS Information and Education Program

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Gabe Kruks

Los Angeles, CA

Rebecca Lane

National Network of Runaway and Homeless Youth

Washington, DC

Reed Larson

University of Illinois at Urbana-champaign

Urbana, IL

T.D. Larson

Federal Highway Administration

U.S. Department of Transportation

Washington, DC

John Laub

Murray Research Center

Radcliffe College

Cambridge, MA

Julia Graham Lear

The School-Based Adolescent Health Cam Program

Children’s Hospital National Medical Center

Washington, DC

Donzella Lee

Watts Health Foundation

Los Angeles, CA

Wooton Lee

Education Week

Washington, DC

Janet Lenart

University of Washington

Seattle, WA
Appendix B-Acknowledgments . I-151

Mary Jean LeTendre

U.S. Department of Education

Washington, DC

Darlene Levenson

National Institute of Child Health and Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Judy Lewis

Office of the Assistant Secretary for Postsecondary

Education

U.S. Department of Education

Washington, DC

Janice G. Lilja

Food and Nutrition Service

U.S. Department of Agriculture

Alexandria, VA

Jean Ann Linney

Department of Psychology

University of South Carolina

Columbia, SC

David Liskowsky

Office of Technology Assessment

U.S. Congress

Washington, DC

Marsha Liss

Claremont, CA

Iris Litt

Division of Adolescent Medicine

Department of Pediatrics

Children’s Hospital

Stanford University

Stanford, CA

Ceola Loan

The School-Based Adolescent Health Care Program

Children’s Hospital National Medical Center

Washington, DC

G.M. Nana Lopez

National Institute of Dental Research

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Ira Lourie

Child and Adolescent Service System Program

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Richard Louttit

National Science Foundation

Washington, DC

Sharon Lovick

Support Center for School-Based Clinics

Houston, TX

Jerry M. Lyle

Indian Health Service

U.S. Department of Health and Human Services

Rockville, MD

Nathan Maccoby

Stanford Center for Research in Disease Prevention

Stanford University School of Medicine

Palo Alto, CA

Socorro Macias

Teen Clinic

Los Angeles High School

Los Angeles, CA

Richard G. MacKenzie

Division of Adolescent Medicine

Children’s Hospital of Los Angeles

Los Angeles, CA

Barbara Malerba

Unified Services

Troy, NY

Fern Marx

Wellesley College

Wellesley, MA

Kenneth Maton

University of Maryland

Baltimore, MD

Jennifer Mayfield

Agency for Health Care Policy and Research

U.S. Department of Health and Human Services

Rockville, MD

Elizabeth McAnarney

University of Rochester Medical Center

Rochester, NY

George McCoy

National Institute of Mental Health

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Robert McDonough

Office of Technology Assessment

U.S. Congress

Washington, DC

J. Michael McGinnis

Office of Disease Prevention and Health Promotion

U.S. Department of Health and Human Services

Washington, DC

Susan McLoughlin

American Nurses Association

Kansas City, MO

Patricia McNeil

Office of Strategic Planning and Development

U.S. Department of Labor

Washington, DC
1-152. Adolescent Health—Volume I

Bill Mehojah

Office of Indian Education

Office of the Assistant Secretary for Elementary

and Secondary Education

U.S. Department of Education

Washington, DC

Deborah W. Meier

central Park East Secondary School

New York, NY

Gary B. Melton

Center on Children, Families, and Law

University of Nebraska, Lincoln

Lincoln, NE

Fernando Mendoza

Children’s Hospital

Stanford University

Palo Alto, CA

James A. Mercy

Center for Environmental Health and Injury Control

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Susan Middlestadt

National AIDS Information and Education Program

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Mary Millar

National Clearinghouse for Alcohol and Drug Information

Rockville, MD

Heather Miller

Institute of Medicine

National Academy of Sciences

Washington, DC

Jeffrey R. Miller

National Highway Traffic Safety Administration

U.S. Department of Transportation

Washington, DC

Leslie Miller

School of Medicine

University of Washington

Seattle, WA

Nicola Miller

Hawaii Department of Health

Honolulu, HI

Susan G. Millstein

Division of Adolescent Medicine

University of California, San Francisco

San Francisco, CA

Wilmer D. Mizell

President’s Council on Physical Fitness and Sports

Washington, DC

Oliver Moles

Office of Educational Research and Improvement

U.S. Department of Education

Washington, DC

Anameli Monroy

Centro de Orientation Para Adolescents, A.C.

Mexico, D.F.

George S. Moore, Jr.

Federal Highway Administration

U.S. Department of Transportation

Washington, DC

Janet Pease Moore

Bureau of Apprenticeship and Training

U.S. Department of Labor

Washington, DC

Kristin A. Moore

Child Trends

Washington, DC

Allyn Mortimer

Carnegie Council on Adolescent Development

Washington, DC

William Mosher

National Center for Health Statistics

Centers for Disease Control

U.S. Department on Health and Human Services

Hyattsville, MD

Alanna J. Moshfegh

U.S. Department of Agriculture

Hyattsville, MD

Edward Mulvey

Law and Psychiatry Program

Western Psychiatric Institute and Clinic

Pittsburgh, PA

Jane Murray

American Academy of Family Practitioners

Kansas City, MO

Regina M. Neal

Office of Planning Services

New York City Health and Hospitals Corp.

New York, NY

Shara Neidell

Center for Population Options

Washington, DC

Paul Newacheck

Institute for Health Policy Studies

School of Medicine

University of California, San Francisco

San Francisco, CA

Eli H. Newberger

Children’s Hospital

Boston, MA
Appendix t?--Acknowiedgments ● /-153

Susan Newcomer

Demographic and Behavioral Sciences Branch

National Institute of Child Health and Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Robert Niblock

Office of Technology Assessment

U.S. Congress

Washington, DC

Elena Nightingale

Carnegie Corporation of New York

Washington, DC

Antonia Novello

Surgeon General

Public Health Service

U.S. Department of Health and Human Services

Washington, DC

Lloyd Olin

Milbridge, ME

Richard Onizuka

Kaiser Permanence

Denver, CO

James Onken

National Institute of Mental Health

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Theodora Ooms

Family Impact Seminar

Washington, DC

Kevin O’Reilly

Division of STDs/HIV Prevention

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Cheryl Ores

Human Resources Division

General Accounting Office

U.S. Congress

Washington, DC

June E. Osborne

School of Public Health

University of Michigan

Ann Arbor, MI

Lowell Overby

Program Services Division

YMCA of the USA

Chicago, IL

Richard Paglinawan

Office of Hawaiian Affairs

Honolulu, HI

Delores Parron

National Institute of Mental Health

Alcohol, Drug Abuse, and Mental Health Administration

US. Department of Health and Human Services

Rockville, MD

Evan G. Pattishall, Jr.

National Institute of Child Health and Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Susan Pearlman

High Risk Youth Program

Los Angeles, CA

John Peel

LA Youth Network

Los Angeles, CA

Stanton Peele

Mathematical Policy Research, Inc.

Princeton, NJ

Jan Phalen

Administration for Native Americans

Office of Human Development Services

U.S. Department of Health and Human Services

Washington, DC

George Pieler

Office of the Deputy Undersecretary for

Planning, Budget, and Evaluation

U.S. Department of Education

Washington, DC

Anthony Pollitt

National Institute of Mental Health

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Martha Poolton

Food and Nutrition Service

U.S. Department of Agriculture

Washington, DC

William Pratt

National Center for Health Statistics

Centers for Disease Control

U.S. Department of Health and Human Services

Hyattsville, MD

Beny J. Primm

Office of Treatment Improvement

Alcohol, Drug Abuse, and Mental Health Adrmini stratio n

U.S. Department of Health and Human Services

Rockville, MD

Sharon Profiter

Uniform Crime Reporting

Federal Bureau of Investigation

U.S. Department of Justice

Washington, DC
~-154 . Adolescent Health—Volume I

Jane Quinn

Carnegie Council on Adolescent Development

Washington, DC

Elizabeth Rahdert

Division of Clinical Research

National Institute on Drug Abuse

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Michael R. Rand

National Crime Survey Unit

Bureau of Justice Statistics

U.S. Department of Justice

Washington, DC

Richard Ratner

Washington, DC

David Reeker

Office of Technology Assessment

U.S. Congress

Washington, DC

Claude Reeder

Office of Policy Analysis

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Gary Remafedi

University of Minnesota

Minneapolis, MN

Michael D. Resnick

Adolescent Health Program

Department of Pediatrics

University of Minnesota

Minneapolis, MN

Everett R. Rhoades

Indian Health Service

U.S. Department of Health and Human Services

Rockville, MD

Dorothy P. Rice

Department of Social and Behavioral Sciences

School of Nursing

University of California, San Francisco

San Francisco, CA

Howard Riddick

Human Nutrition Information Service

U.S. Department of Agriculture

Hyattsville, MD

Lynn Ries

National Cancer Institute

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Richard RimKunas

Congressional Research Service

U.S. Congress

Washington, DC

Sue Ann Ritchko

Human Nutrition Information Service

U.S. Department of Agriculture

Hyattsville, MD

Linda Roberts

Office of Technology Assessment

U.S. Congress

Washington, DC

Marjorie Robertson

University of California, Berkeley

Berkeley, CA

Gail K. Robinson

Mental Health Policy Resource Center

Washington, DC

William Robinson

Office of Minority Health

Office of the Assistant Secretary for Health

U.S. Department of Health and Human Services

Washington, DC

Helen Rodriguez

Medical Director

AIDS Institute

New York, NY

Denise Rosario

Brooklyn Child and Family Services, Inc.

Brooklyn, NY

Mark L. Rosenberg

Office of the Deputy Director (HIV)

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Susan Rosenzweig

University of North Carolina at Chapel Hill

Carrboro, NC

Joseph Ruby

Wiley, Rein & Fielding

Washington, DC

Stanley Ruby

Garrett Park, MD

Carol W. Runyan

The University of North Carolina Injury Prevention

Research Center

Chapel Hill, NC

Cheryl Rust

Metropolitan Washington Council of Governments

Washington, DC

Pat Ryan

National Association of Private Psychiatric Hospitals

Washington, DC

Rose Sabo

Civilian Health and Medical Program of the Uniformed

Services

U.S. Department of Defense

Denver, CO
Appendix E--Acknowledgments ● I-155

Patricia Salomon

Special Populations Program Development Division

Bureau of Health Care Delivery and Assistance

U.S. Department of Health and Human Services

Rockville, MD

Nancy Saltford

Home Economics and Nutrition

U.S. Department of Agriculture

Washington, DC

Frank Sanchez

Kips Bay Boys and Girls Club

Bronx, NY

Joe M. Sanders

American Academy of Pediatrics

Elk Grove Village, IL

Daniel Santisteban

Spanish Family Guidance Center

University of Miami

Miami, FL

Martha Schiebel

Washington, DC

Ira Schwartz

School of Social Work

University of Michigan

Ann Arbor, MI

David G. Scherer

Department of Psychology

University of South Carolina

Columbia, SC

Robert A. Scholle

Office of Population Affairs

Office of the Assistant Secretary for Health

U.S. Department of Health and Human Services

Washington, DC

Judith Schrag

U.S. Department of Education

Washington, DC

Dianne Scott-Jones

University of Illinois at Urbana-Champaign

Urbana, IL

Nancy Sefcik

Western States Youth Services Network

Setaluma, CA

Ann Segal

Office of Social services Policy

U.S. Department of Health and Human Services

Washington, DC

Mona Seliger

Office of Planning Services

New York City Health and Hospitals Corp.

New York, NY

Judith Senderowitz

Center for Population Options

Washington, DC

John Sexton

Stepping Stone

Santa Monica, CA

Mary-Ann B. Shafer

Division of Adolescent Medicine

University of California, San Francisco

San Francisco, CA

Aaron N, Shedd

Office of Indian Education

U.S. Department of Education

Washington, DC

Melissa Shepherd

National AIDS Information/Education Program

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

David Siegal

Office of Communications

Family Support Administration

U.S. Department of Health and Human Services

Washington, DC

Jane Sisk

Office of Technology Assessment

U.S. Congress

Washington, DC

Ronald Slaby

Education Development Center

Newton, MA

Benjamin Smith

Washington, DC

Phil smith

U.S. Department of Health and Human Services

Washington, DC

Lonnie Snowden

University of California, Berkeley

Berkeley, CA

Howard Snyder

National Center for Juvenile Justice

Pittsburgh, PA

Lois Snyder

American College of Physicians

Philadelphia, PA

Walter Solarz

Mental Health Center of Wood County

Bowling Green, OH

Diane Sondheimer

National Institute of Child Health and Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD
I-156 ● Adolescent Health—Volume I

Sandra Spaulding

Administration for Native Americans

Office of Human Development Services

U.S. Department of Health and Human Services

Washington, DC

Greg Spencer

Bureau of the Census

U.S. Department of Commerce

Washington, DC

Marilyn Price Spivack

National Head Injury Foundation

South Borough, MA

Jeanne Spurlock

American Psychiatric Association

Washington, DC

Stephen Sroka

Health Education Consultants

Lakewood, OH

Suzanne Stack

National Transportation Safety Board

Washington, DC

Laurence Steinberg

Department of Psychology

Temple University

Philadelphia, PA

Vivien Stewart

Program on Healthy Child Development: The Prevention

of Damage to Children

Carnegie Corporation of New York

New York, NY

Arlene R. Stiffman

Washington University in St. Louis

St Louis, MO

Elaine Stone

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

Mary Story

University of Minnesota

Minneapolis, MN

Joyce Strom

Child Welfare League of America

Washington, DC

Candace Sullivan

National Association of State Boards of Education

Alexandria, VA

Thomas Sullivan

Office of Analysis and Evaluation

Food and Nutrition Service

U.S. Department of Agriculture

Alexandria, VA

Barry Sweedler

Bureau of Safety Programs

National Transportation Safety Board

Washington, DC

Ruby Takanishi

Carnegie Council

Washington, DC

Jane A. Taylor

on Adolescent Development

National Institute on Alcohol Abuse and Alcoholism

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

A.K. Thakkar

Washington, DC

Sager Thakkar

Washington, DC

Robert L. Thomas

National Association of Private Psychiatric Hospitals

Washington, DC

Linda Thompson

Office of Occupational Medicine and Safety

Baltimore City Government

Baltimore, MD

Sarah Thrift

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

Nancy Tobler

Center for Social Work Practice Research

State University of New York at Albany

Albany, NY

Arnold Tompkins

Office of the Secretary

U.S. Department of Health and Human Services

Washington, DC

Itihari Toure

LA Regional Family Planning council

Los Angeles, CA

Margi Trapani

Child Health and Development

Scientists’ Institute for Public Information

New York, NY

Charles Turner

National Academy

Washington, DC

Forrest Tyler

of Sciences

University of Maryland

College Park, MD

Natalie Updegrove

Food and Nutrition Information Center

U.S. Department of Agriculturc

Beltsville, MD
Appendix B-Acknowledgments . I-157

Gene Urbain

Amherst H. Wilder Foundation

St Paul, MN

Maria E. Vegaga

National Highway Traffic Safety Admini stration

U.S. Department of Transportation

Washington, DC

Stephanie Ventura

National Center for Health Statistics

Centers for Disease Control

U.S. Department of Health and Human Services

Hyattsville, MD

Cheryl J. Vince

Educational Development Center, inc.

Newton, MA

Thomas Vischi

Office of Treatment Improvement

Alcohol, Drug Abuse, and Mental Health Administration

U.S. Department of Health and Human Services

Rockville, MD

Pam Wagner

Reseda, CA

Michael Wald

University of Chicago Law School

Chicago, IL

Joyce Walker

Adolescent Health Program

University of Minnesota

Minneapolis, MN

Julian A. Wailer

University of Vermont

Burlington, VT

Patricia Wailer

University of Michigan

Ann Arbor, MI

Deborah Walter

Child Health and Development Program

Scientists’ Institute for Public Information

New York, NY

Cathy J. Wasem

Office of Rural Health Policy

Health Resources and Services Administration

U.S. Department of Health and Human Services

Rockville, MD

Ruth Wasem

Congressional Research Service

U.S. Congress

Washington, DC

Margaret Washnitzer

Family Support Administration

U.S. Department of Health and Human Services

Washington, DC

Cindy Waszak

Center for Population Options

Washington, DC

Jerry M. Weiner

George Washington University

Washington, DC

Karen Weinstein

Los Angeles, CA

Rita S. Weiss

National Highway Traffic Safety Administration

U.S. Department of Transportation

Washington, DC

Barbara Whelan

Bridge Over Troubled Waters

Boston, MA

Kathy Whitaker

National Crime Survey Unit

Bureau of Justice Statistics

U.S. Department of Justice

Washington, DC

Linda Johnson White

American College of Physicians

Philadelphia, PA

Michelle White

The Door

New York, NY

Valerie White

Association of State and Territorial

Health Officials

McLean, VA

Cathy Spatz Widom

Departments of Criminal Justice and Psychology

Indiana University

Bloomington, IN

Brian Wilcox

American Psychological Association

Washington, DC

Becky Williams

Child and Adolescent Health Division

Arkansas Department of Health

Little Rock, AK

James B. Williams

Office of the Assistant Secretary for Postsecondary

Education

U.S. Department of Education

Washington, DC

Prenis Williams

City of Austin Parks and Recreation Department

Austin, TX

Yolanda Williams

LA Regional Family Planning council

Los Angeles, CA
I-158 ● Adolescent Health—Volume I

Anne Willoughby

National Institute of Child Health and Human Development

National Institutes of Health

U.S. Department of Health and Human Services

Bethesda, MD

J. Harper Wilson

Uniform Crime Reporting Program

Federal Bureau of Investigation

U.S. Department of Justice

Washington, DC

Renee Wilson

City Health Department

Health Promotion Program for Urban Youth

Department of Health and Hospitals

Boston, MA

Ken Winters

Center of Adolescent Substance Abuse

Adolescent Health Program Hospital and Clinic

Minneapolis, MN

Rebecca Wolf

Office of Program Planning and Evaluation

Centers for Disease Control

U.S. Department of Health and Human Services

Atlanta, GA

David Wood

Cedar-Sinai Medical Center

Los Angeles, CA

Tom Wyld

National Rifle Association

Washington, DC

W. Yarber

Department of Applied Health Science

Indiana University

Bloomington, IN

Gary Yates

Division of Adolescent Medicine

Children’s Hospital

Los Angeles, CA

Philip Ziring

Pacific Presbyterian Medical Center

San Francisco, CA
ISSUES RELATED TO THE LACK

ADOLESCENT HEALTH AND HEALTH

Appendix C

OF INFORMATION ABOUT

AND RELATED SERVICES

In this Report, OTA was able to draw broad general

conclusions about the prevention and treatment of adolescent health problems, but it is important to note that

OTA’s analysis was often severely hampered by insufficient information. A paucity of information about adolescent health concerns makes definitive conclusions about

the extent of health problems among U.S. adolescents and

about the availability and appropriateness of efforts to

prevent and treat the problems (and promote positive

adolescent health) difficult to draw. This paucity of

information deserves specific attention in and of itself

because it is an area particularly amenable to Federal

attention. 1

The assessment of adolescent health and health care is

impeded by a paucity of information in two main areas:

1. information related to the health status of adolescents, and

2. information on prevention- and treatment-oriented

health services available to adolescents.

Limitations of Information on Adolescents’

Health Status

Efforts to assess the health status of adolescents are

universally stymied by at least two barriers: 1) limited

conceptualizations of health, and 2) unusable and inconsistent aggregations of data by age, which in combination

with small sample sizes, make analyses of available health

status information difficult.

Indicators of health status are typically disease focused,

with mortality due to natural causes and physician visits

for disease being two of the few outcomes measured.

Examples of such indicators appear in two publications of

the U.S. Department of Health and Human Services

(DHHS), Health, United States, 1989 (289) and Healthy

People (260).

As discussed elsewhere in this Report, definitions of

health are in flux; thus, it is difficult to define all the

parameters of health for any given Population.z Even for

the parameters of adolescent health that have generally

been agreed upon, however, data are rarely collected in

any one place. For OTA’s Adolescent Health Report (and

similar compilations of data3), therefore, it was necessary

to derive data from a variety of sources, and to request

special data analyses.4 For many important adolescent

problems (e.g., nonfatal accidents, sexually transmitted

diseases, delinquency, mental health problems, hopelessness), there are no reliable sources of national data.

Aggregations of Data by Age Groupings

There is no single agreed-upon definition of adolescence, and chronological age is a poor proxy for

developmental status (150); criticisms of current data

collection by age groupings may therefore seem out of

place. Currently, however, most published data make it

difficult to disaggregate data for any semblance of an

adolescent age group, especially if one considers the onset

of puberty (which generally occurs between ages 10 and

IAs noted in OTA’S 1988 repofi, The Quality of Medical Care: [nformafion for consumers, there 1S a cOnSenSu5, if not unanimity, that the Federat

Government should play a centrat role in the collection and dissemination of information (225).

2Sm ~x A, in ‘‘Major Findings, ’ and ch. 2, “What Is Adolescent Health?’ in Vol. II, for a discussion of the ways in which adolescent health has

been conceptualized.

sRmenl exmples of Compilatlom of adole~ent he~~ sta~s &@ include tie American M~ic~ Ass~iation’s publicatio~ America’s Adolescents:

How Healdty Are They? (8); the Carnegie Council on Adolescent Development’s publication Thrning Points: Preparing American Youfhfor the 21st

Century (29); the Nationat Center for Education in Maternal and Child Health’s publication The Health of America’s Youth (150); ~d tie Natio@

Commmsion on the Role of the School and the Community in Improving Adolescent Health’s publication, Code Blue: Uniting for Healthier Youth ( 153).

dFor ~omatlon abut adolescenfi’ sexu~ activi~, for example, OTA sought information from the National Survey of F~lY Grow~ conduct~

by the Nationat Center for Health Statistics in DHHS; for information about deaths, national vitat statistics maintained by the National Center for Heatth

Statistics in DHHS; for information about health care utilization, the Nationat Ambulatory Medical Care Survey and the National Health Interview

Survey conducted by the National Center for Health Statistics in DHHS; for information about school attendance, the U.S. Department of Education;

for information about drug use, the National Household Survey of Drug Use conducted by the National Institute on Drug Abuse in DHHS, the Monitoring

the Future/High School Seniors Survey conducted by University of Michigan researchers under contract to the National Institute on Drug Abuse in

DHHS, and school surveys spon..orcd by the Centers for Disease Control in DHHS; for information about delinquency, the Uniform Crime Reports of

the Federal Bureau of investigation within the U.S. Department of Justice.

-1-159-
I-160 Adolescent Health—Volume I

14) to be the beginning of adolescence.s6 Only recently

has the Bureau of Maternal and Child Health in DHHS

published a volume on the health of youth in which some

limited data are reported for 10- to 14- and 15- to

19-year-olds (150).

Because of the many problems in aggregations of data,

even the assembly of data to describe adolescent health

using admittedly gross indicators such as age becomes a

major task. Not surprisingly, therefore, there is no regular

monitoring of US. adolescents’ health.

Small Sample Sizes

The problem of unusable aggregations of data would be

amenable to solution by interested researchers if sample

sizes were large enough so that individual years of age

could be disaggregated and reaggregated, although conducting these reaggregations would be difficult because

of difficulties in gaining access to the data.7 Disaggregating and reaggregating data is sometimes possible (e.g.,

mortality data, arrest data). Often, however, that approach

is impossible because the data have been collected by

methods that do not oversample for adolescents. Surveys

that do not oversample for adolescents include the

National Hospital Discharge Survey (NHDS),8 the National Ambulatory Medical Care Survey (NAMCS), the

National Health and Nutrition Examination Survey

(NHANES III),9 and the National Drug and Alcoholism

Treatment Unit Survey (NDATUS).1

°

The problem of small sample sizes becomes particularly acute when attempts are made to assess the health

status of adolescents by region, residence,ll race, ethnicity, age, sex, or socioeconomic status. Such analyses are

important when one is attempting to identify groups of

adolescents or geographic areas in special need of

services. NHANES III, currently in the field, illustrates

the problem. NHANES III is scheduled to collect data

from only 1,120 black, 1,120 Hispanic, and 980 “white

and other” 12- to 19-year-olds. With an estimated 34.762

million 12- to 19-year-olds in the United States in 1989,

each adolescent surveyed will have to represent 10,796

adolescents of that age group. Thus, one would expect that

only broad generalizations about adolescent health will be

able to be made from NHANES III.12

Information on Income Status

OTA was consistently frustrated in attempts to disaggregate differences in health status apparently associated

with race and ethnicity from differences truly associated

with family income, primarily because information on

income (unlike information on race and ethnicity) is

almost never collected along with health information. As

a result, problems which are often attributed to problems

associated with one race or another may in fact be more

properly attributed to socioeconomic (or other) differences,

Information on Health From the Perspective

of Adolescents

One of the hallmarks of adolescent development is the

increasing ability to evaluate one’s self and surroundings,

A perhaps related hallmark is the tendency to withhold

information from others in one’s immediate environment,

such as parents. Rarely, however, are U.S. adolescents

asked to report about aspects of their health other than

their engagement in problem behaviors.

5S= Ch. 2, “~t Is Adolescent Health?” in Vol. II, for a discussion of adolescent development.

6Age ~oup~s ~ ~de]y av~ble dab ~Wes included the following: ages 5 to 14 and ages 15 to 24 in mortality data pubhsh~ in Hea~t~t U~ited

States, 1989 (289); ages 5 to 14 and ages 15 to 44 in National Health Interview Survey data on physician utilization published in Zfeuhh, United Stares,

1989; ages 15 to 24 (with no younger ages reported) in information on methods of contraception from the National Survey of Family Growth published

in Health, United States, 1989; ages 15 and under and ages 15 to 24 in various data published in Health, Um”tedStates, 1989 and in Healthy People (260);

less than age 18 and agw 18 to 19 in data on age of mother at birth of child published in Health, United States, 1989; under age 18 and ages 18 to 44

in data on specific chronic and acute conditions from the National Health Interview Survey (286); under age 18 and over age 18 in data on arrests from

the U.S. Department of Justice (303); under age 18 and ages 18 to 64 in Current Population Report data on poverty status from the Census Bureau of

the U.S. Department of Commerce (246); and 8th graders, I(kh graders, and both grades combined in a unique national sumey of adolescent attitudes

(10). Other sources of data, with freer age categories are published, but are not widely available,

%fOR Feded data collection agencies are making data available ekchutically, but manipulation of the data requires special skills and access to

appropriate computer software and hardware. Obtaining data from extragovernmental sources may be difficult because such data analyses are subject

to long publication processes (if conducted by independent researchers) or because the analyses are kept by a local agency and not distributed,

8TW~c~y,-s,NAMCS, NDATUS, md the Natio~ Insti@te of Mental Health’s surveys of mental health oretions involve dam about

health cam utilization not health status. Sometimes, however, data from these sources are used to make inferences about health status. If health care

utilkmion rates are low, for example, it is sometimes inferred that a population has good health. One problem with such an inference is that it does not

take into account the possibility that low utilization rates may be caused by barriers to access.

%IHDS, NAMCS, and NHANES are discussed in ch. 6, ‘‘Chronic Physical Illnesses: Prevention and Services, ’ in Vol. II.

IO~A~S is diXu5W h ch. 12, 1‘Alcohol, Tobaao, and Drug Abuse: Prevention and Services, ” in Vol. H.

I lh U.S. Census Bureau terminology, “residence’ signitles metropolitan area, nonmetropolitan area, central city, etc. (109).

12~e Center5 for Dl=se Con~ol ~ D~S is fiti~ting a coop~tive pro- wi~ S@te ~ucation dep~ents to ~Umt re@ar, loctdly mleWXlt

data on adolescent “risk behaviors” (277). It is important to note, however, that this effort is limited to self-report data on selected behaviors. Effoxts

tike NHANES actually conduct health examina tions of individual participants.
Appendix C—Issues Related to the Lack of lnfortnation About Adolescent Health and Health and Related Services . 1-161

Limitations of Information About Health

Promotion, Disease Prevention, and Treatment

Information on health care provided to U.S. adolescents is even more limited than information on such

adolescents’ health status. 13 Surveys of private officebased physician visits and analyses of hospital discharge

data, for example, do not oversimple for adolescent visits

(or practitioners who might see adolescents), so inferences about the utilization of mainstream health care by

adolescents are difficult to draw. There is no single source

of information about nonphysician providers and other

sources of health care for adolescents, including hospitalbased and freestanding emergency rooms, school nurses,

and school-linked health centers. Despite the problems,

some broad inferences can be made about adolescents’

utilization of mainstream sources of health care, but when

the topic of interest is health care utilization by racial and

ethnic minority adolescents, adolescents of varying levels

of socioeconomic status, or adolescents in specific

regions or residential areas, inferences are far more

difficult to draw.14

Another problem is that numerical data on health care

utilization do not address the important issue of whether

care provided to adolescents is appropriate, effective, and

satisfactory to the adolescent users. Either there are no or

almost no evaluations (e.g., acne treatment, treatment for

dysmenorrhea, substance abuse treatment, treatment in

juvenile justice facilities, school-linked health services

centers), or serious methodological flaws hamper efforts

to draw conclusions from available evaluations. Marty of

the methodological flaws can be attributed to common

problems (e.g., low base rate of the health problem, little

funding for objective evaluations, inadequate requirements for methodological criteria).

l~As ~oted ~~vc, h~lth care ~tlllmtlon ~~ tie sometfies used as the bmis of inferences about health status; therefore, some sources Of health

ufiliza(ion data (c, g., NAMCS, NHDS, NDATUS ) were referred to above in the dismssion of health status information.

14Such Inferences arc presented in Vol. HI inch. 15, ‘ ‘Major Issues Pertaining to the Delivery of Primary and Comprehensive Services to Adolescents.

For further dlscusslon, SEX ch 18, ‘‘Issues in the Delivery of Services to Selected Groups of Adolescents, ’ in Vol. III.
Appendix D

GLOSSARY OF ABBREVIATIONS AND TERMS

Abbreviations

AFDC —Aid to Families With Dependent Children

AIDS —acquired immunodeficiency syndrome

DHHS —U.S. Department of Health and Human

Services

EPSDT —Early and Periodic Screening, Diagnosis,

and Treatment program (Medicaid)

HCFA —Health Care Financing Administration

—human immunodeficiency virus (AIDS virus)

OBRA-89 -Omnibus Budget Reconciliation Act of

1989 (Public Law 101-239)

OBRA-90 -Omnibus Budget Reconciliation Act of

1990 (Public Law 101-508)

OTA ----Office of Technology Assessment (U.S.

Congress)

STD —sexually transmitted disease

Terms

Access: Potential and actual entry of a population into the

health care delivery system. Elements of access

include availability, affordability, and approachability y.

Accidental injury: An injury that is not self-inflicted or

caused by maltreatment or other violence.

Acne (vulgaris): A chronic inflammatory disease of the

pilosebaceous apparatus (i.e., hair follicles and sebaceous glands), the lesions occurring most frequently on

the face, chest, and back. The cause is unknown.

Acute condition: A problem or disease of limited

duration, as opposed to chronic. According to the

DHHS National Center for Health Statistics, a condition is considered acute if: 1) it was first noticed no

longer than 3 months before the reference date of the

interview, and 2) it is not one of the conditions

considered chronic regardless of the time of onset.

However, any acute condition not associated with

either at least one doctor visit or at least 1 day of

restricted activity is considered to be of minor consequence and is excluded from the final data produced by

the DHHS National Center for Health Statistics’

National Health Interview Survey.

Addiction model: A model of treatment for alcohol and

drug abuse based on the philosophy that once a person

has become a problem user of alcohol or drugs, he or

she will always be a problem user and should avoid any

use of alcohol and drugs for life.

Adolescence: Definitions of adolescence vary, and many

observers agree that a definition based on age alone is

not sufficient. Adolescence typically takes place during the second decade of life, and is initiated by

puberty, although physical and other changes occur

(i.e., in height, weight, head size, facial structure, facial

expression, and cognitive abilities). As used by OTA,

adolescence most often refers to the period of life from

ages 10 through 18. See early adolescence, middle

adolescence, late adolescence, younger adolescents,

older adolescents.

Adolescent health: Narrow definitions of adolescent

health might be the absence of physical disease and

disability and the absence of engagement in healthcompromising behaviors that lead to the so-called

‘‘new morbidities. ” A broader definition would also

include positive components of health (e.g., social

competence); health and well-being from the perspectives of adolescents themselves (e.g., perceived quality

of life). A fully realized view of adolescent health

would also consider the impact of social (e.g., families,

schools, communities, policies) and physical (e.g.,

fluoridation, automobile and highway design and

construction) influences on health and would be

sensitive to developmental changes that occur during

adolescence. See also health.

Advocacy: Refers to support, coordination and linkage to

experts, individuals, groups, and institutions who may

help adolescents. May be provided by parents or others

known to an adolescent.

Age of majority: The age at which by law a person is

entitled to the management of his or her own affairs

and to the enjoyment of civic rights. Currently, the age

of majority is set at age 18 in every State but Alaska,

Nebraska, and Wyoming, where the age is 19.

Aggravated assault: See assault.

AIDS (acquired immunodeficiency syndrome): A disease caused by human immunodeficiency virus (HIV)

and characterized by a deficiency of the immune

system. The primary defect in AIDS is an acquired,

persistent, quantitative functional depression within

the T4 subset of lymphocytes. This depression often

leads to infections caused by micro-organisms that

usually do not produce infections in individuals with

normal immunity. HIV infection can be transmitted

from one infected individual to another by means that

include the sharing of a contaminated intravenous

needle and engaging in unprotected sexual intercourse

(i.e., intercourse without the use of condoms).

Aid to Families With Dependent Children (AFDC)

program: A program, established by the Social Security Act of 1935, providing cash payments to needy

children (and their caretakers) who lack support

because at least one parent is dead, disabled, continually absent from the home, or unemployed. Eligible

-1-162-
— .—

Appendix D--Glossary of Abbreviations and Terms . I-163

families must meet income and resource criteria

specified by the State.

Airbag: An automatically inflating bag in front of riders

in an automobile to protect them from pitching forward

into solid parts in case of an accident.

Alcohol abuse: See substance abuse.

Alcohol, drug abuse, and mental health (ADM) block

grant: The major Federal program providing funds to

States for outpatient alcohol, drug abuse, and mental

health treatment programs. (Funds are not allowed to

be used for inpatient services.) States receive a share

of the ADM block grant appropriation through a

formula based in part on the size of the State

population (Subpart 1, part B of Title XIX of the Public

Health Service Act). The ADM block grant consolidated funds that were formerly made available under

a variety of categorical programs, most significantly

programs under the Community Mental Health Centers Act of 1963. The ADM block grant is administered

by the Office of Treatment Improvement in the

Alcohol, Drug Abuse, and Mental Health Administration in DHHS.

Alternatives programs: Programs that provide alternatives to life in the drug culture, such as recreation and

sports programs and outward bound-type camping

efforts.

Ambulatory care: Health care services provided to

patients who are not inpatients of hospitals or other

residential facilities (e. g., residential treatment centers,

nursing homes). It includes care provided in a hospital

on an outpatient basis.

American Indians and Alaska Natives: See Indian.

Analgesic: Ingested substance that acts as a pain reliever.

Anticipatory guidance: Counseling about topics important to health, optimally provided before such problems have arisen.

Anxiety disorders: Mental disorders in which excessive

anxiety is the primary symptom. Separation anxiety

disorder involves irrational fears or panic about being

separated from those to whom one is attached, usually

the parent(s). While separation anxiety disorder is

more common among children, it may continue into

adolescence.

Arrest rate: The number of arrests made in a given

population per some population base during a given

time period.

Assault: Unlawful intentional inflicting, or attempted

inflicting, of injury upon the person of another. Simple

assault is the unlawful intentional inflicting of less

than serious bodily injury without a deadly or dangerous weapon or an attempt or threat to inflict bodily

injury without a deadly or dangerous weapon. Aggravated assault is the unlawful intentional inflicting of

serious bodily injury or death by means of a deadly or

dangerous weapon with or without actual infliction of

injury.

Asthma: A disorder of the bronchial tubes, producing

wheezing and difficulty in breathing.

“At risk”: A phrase used to describe an adolescent in an

environment, having an existing health problem, or

exhibiting behavior, that may result in a poor health

outcome.

Authoritative parenting: A combination of open communication, and give-and-take between parent and

adolescent, in an environment of consistent support

and firm enforcement of unambiguous rules. Authoritative parents are neither authoritarian (harsh, rigid,

domineering), overindulgent, indifferent, nor rejecting.

Base rate: The prevalence or incidence of a problem in

a population.

Behavioral problems: Behavior that disturbs or harms

the adolescent or others. Includes the mental health

problems termed behavior disorders (e.g., attention

deficit disorder, conduct disorder). See problem behavior-s. Compare physical problems.

Block grants-Sums of Federal funds allotted to State

agencies (e.g., education, health) which may be passed

onto local agencies. States determine the mix of

services provided and the population served and are

accountable to the Federal Government only to the

extent that funds are spent in accordance with program

requirements. Sometimes, however, set-asides are

required for specific population groups.

Broad-based (programs): Typically, programs that take

a comprehensive rather than a narrow approach to

addressing a single health problem, such as by

involving multiple service systems or strategies (e.g.,

a pregnancy prevention intervention that would involve teaching of life skills and vocational training, as

well as provide sexuality education) and possibly by

measuring multiple theoretically and practically related outcomes (e.g., avoidance of school dropout as

well as pregnancy prevention).

Caries: See dental caries.

Categorical requirements: Requirements that an individual must fit a certain category of need in order to be

eligible for assistance. See Aid to Families With

Dependent Children (AFDC) program.

Cerebral palsy: Any paralysis or other dysfunction due

to perinatal damage to the motor areas of the brain.

Perinatal damage is damage taking place around the

time of birth.

Child allowances: Sums provided to parents based on the

number of children in the household.

Child welfare services: See social services.

Children’s protective services: See protective services.

Chlamydia: A sexually transmitted disease that is

characterized by infection with the bacterial agent

Chlamydia trachomatis. Infection with this bacterial

agent can cause nongonococcal urethntis and other

syndromes (e. g., genital ulceration) and may lead
I-164 ● Adolescent Health—Volume I

eventually to meningitis, pneumonia, blindness, and

cervical atypia.

Chronic condition: A problem or disease that is lingering

and lasting, as opposed to acute. For purposes of

DHHS’s National Health Intenview Survey, a condition is considered “chronic” if: 1) the respondent

indicates it was first noticed more than 3 months before

the reference date of the interview and it exists at the

time of the inteview, or 2) it is a type of condition that

ordinarily has a duration of more than 3 months.

Examples of conditions that are considered chronic

regardless of their time of onset are diabetes, heart

conditions, emphysema, and arthritis.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS): A health insurance

program, administered by the U.S. Department of

Defense, that provides health benefits to military

dependents and retirees who are unable to receive

services through uniformed service medical treatment

facilities.

Clinical trial: A scientific research activity undertaken to

define prospectively the effect and value of prophylactic, diagnostic, or therapeutic agents, devices, regimens, procedures, etc., applied to human subjects.

Cocaine: An addictive psychoactive substance obtained

from coca leaves that is a central nervous system

stimulant.

Cognitive interventions (in health care): Interventions

that rely heavily on interpersonal interaction (e.g.,

counseling) as opposed to more impersonal (technical)

services.

Cognitive skills: Specific skills relevant to higher order

reasoning and critical thinking. Often part of life -skills

training programs.

Common law: As distinguished from statutory law

created by a legislature, the body of principles and

rules of action which derive their authority solely from

long-standing usages and customs (in particular,

Anglo-American usages and customs) or from the

judgments and decrees of the courts recognizing,

affirming, and enforcing such usages and customs.

Common law rule: A rule grounded in common law (see

above) rather than in statutory law.

Community-based comprehensive health centers: Used

to refer to those centers providing comprehensive

health and/or related services that are situated in the

adolescents’ home community, but are not schoollinked.

Competence (to make health care decisions): Having

sufficient knowledge, judgment, or skill to make

health care decisions. The legal concept of competency

is central to existing laws governing health care

decisionmaking with respect to minors, and the

parental consent requirement is partially an outgrowth

of the presumption that minors are incompetent to

make health care decisions.

Comprehensive services for adolescents: The elements

of comprehensive health and related services for

adolescents are not entirely agreed upon. They include,

at a minimum, care for acute physical illnesses, general

medical examinations in preparation for involvement

in athletics, mental health counseling, laboratory tests,

reproductive health care, family counseling, prescriptions, advocacy, and coordination of care; the more

comprehensive may include educational services,

vocational services, legal assistance, recreational opportunities, child care services and parenting education

for adolescent parents. Not all services are available at

all centers, but a well-functioning comprehensive

services center would provide for the coordinated

delivery of care both within the center and between the

center and outside agencies and providers.

Condition: A general term that includes any specific

illness, injury, or impairment.

Condition-specific: A program or policy relevant to a

specific illness, injury, impairment, or other health or

related concern, as opposed to an entire population and

its health concerns (e.g., women, minorities, children,

adolescents).

Condom: A sheath commonly made of rubber worn over

the penis for the purpose of preventing conception or

the transmission of AIDS or other sexually transmitted

diseases.

Conduct disorder: A mental disorder diagnosed on the

basis of a pattern of behavior (lasting at least 6 months)

in which a young person violates others’ rights as well

as age-appropriate social norms and displays at least 3

of 13 specified behavioral symptoms (e.g., truancy,

lying, stealing, fighting).

Confidentiality (of the physician/patient relationship):

The state or quality of being confidential, that is

intended to beheld in confidence or kept secret. Courts

and legislatures have established a physician-patient

privilege to protect the confidentiality of communications between physicians and their patients and have

established similar privileges to ensure the confidentiality of communications between other types of health

care providers and their patients or clients. By and

large, the confidentiality of the relationship between

health service providers and minors and the disclosure

of confidential information by health service providers

to the parents of minors or other third parties are not

addressed in case or statutory law. See also parental

consent requirement and parental notification.

Congenital: Existing at birth.

Consent; See informed consent, parental consent requirement.

Contraception: The prevention of conception or impregnation by any of a variety of means, including periodic

abstinence (rhythm method); control of ejaculation

(coitus interrupts); the use of spermicidal chemicals

in jellies or creams; mechanical barriers (e.g., con-
Appendix D--Glossary of Abbreviations and Terms . I-165

doms, caps, or diaphragms); prevention of implantation (e.g., intrauterine device); the use of synthetic

hormones to control the female reproductive cycle

(e.g., the oral contraceptive pill); and sterilization of

the male or female partner.

Covariation: The tendency of health problems to occur

in the same individual at approximately the same time.

The problems may have a single common cause, or one

problem may be the cause of another.

Crisis intervention services: A not well-defined set of

mental health services that can include crisis telephone

lines (i.e., hot lines), emergency outpatient services,

and a range of crisis-oriented outreach services such as

home-bused care and mobile crisis teams.

Culturally competent: A set of congruent behaviors,

attitudes, and policies that come together in a system,

agency, or among professionals and enables that

system, agency, or those professionals to work effectively in cross-cultural situations. A culturally competent system of care acknowledges and incorporates-at

all levels—the importance of culture, the assessment

of cross-cultural relations, vigilance towards the dynamics that result from cultural differences, the

expansion of cultural knowledge, and the adaptation of

services to meet culturally unique needs. See culture.

Culture: Implies the integrated pattern of human behavior that includes thoughts, communications, actions,

customs, beliefs, values, and institutions of a racial,

ethnic, religious or social group.

Cystic fibrosis: An autosomal recessive disorder caused

by the production of a unique glycoprotein that results

in abnormal mucous secretions. It is one of the most

common genetic diseases in caucasian children, and is

most often seen in children and young adults. It is

usually fatal before age 20. Death is due to excess

mucus in the lungs and to pancreatic insufficiency.

Day treatment: A nonresidential mental health service

that provides an integrated set of educational, counseling, and family interventions which involve a child or

adolescent for at least 5 hours a day, and that can be

provided in school setting, community mental health

centers, hospitals or elsewhere in the community. Day

treatment programs that are provided in hospitals are

referred to as partial hospitalization. Day treatment is

considered the most intensive of the nonresidential

services that can continue over a longer period of time.

Death rate: The number of deaths per some portion of a

population, usually 100,000 individuals.

Decisionmaking skills: Skills relevant to the ability to

make rational, health-promoting decisions about one’s

life. Often a part of life-Skills training interventions,

Delinquent behavior: Includes two types of acts: 1) acts

committed by minors that would be considered crimes

if committed by an adult, and 2) status offenses (i.e.,

acts that are offenses solely because they are committed by a juvenile, such as running away from home,

truancy). See minor offenses and serious offenses.

Demonstration project: An intervention that is typically

in an experimental (unproven) stage of effectiveness

and is supported for a limited period with an evaluation

component.

Dental caries: The localized, progressive decay of a

tooth, starting on the surface, and if untreated, extending to the inner tooth chamber and resulting in

infection.

Dental and oral health: The term dental means of or

relating to the teeth or dentistry (the health profession

that cares for teeth); and the term oral means of or

relating to all aspects of the oral cavity (such as the

gums and the tongue). Thus, dental and oral health

refers to the health of these structures.

Dependency ratio: The number of children and elderly

people per every 100 people of working age.

Depression: A mental disorder characterized by prolonged and intense feelings of worthlessness, hopelessness, or irritability and thoughts of death or suicide.

Designated driver (programs): The practice of a group

designating a person in the group to not drink alcohol

and to be the driver for others who may be drinking

beverage alcohol.

Development: A process of growth and differentiation by

successive changes. In humans, includes physiological

development; cognitive development (increasing ability to think critically and engage in higher order

reasoning); ego development (qualitatively different

psychosocial stages, including internalization of the

rules of social intercourse, increasing cognitive complexity and tolerance of ambiguity, and growing

objectivity); and moral development (changes in the

ability to recognize and reason about moral dilemmas

and to make choices based on moral principles and

reasoning).

Developmentally appropriate: Health promotion, prevention, and treatment services and environments

designed so that they fit the emotional, behavioral/

experiential, and intellectual levels of the individual

who is to benefit from the service. Because of the

asynchronous development within even individual

adolescents (as well as individuals in other age

categories), designing programs so that they are

developmentally appropriate is a distinct challenge.

Diagnosable mental disorders: Disorders included in

the American Psychiatric Association’s Diagnostic

and Statistical Manual of Mental Disorders, 3d cd.,

revised.

Disability: A term used to denote the presence of one or

more functional limitations. A person with a disability

has a limited ability or an inability to perform one or

more basic (daily) life functions (e. g., walking) at a

level considered “typical.”
I-166 ● Adolescent Health—Volume I

Discretionary spending programs (in the Federal

budget): Those spending programs subject to the

annual appropriations process. Compare entitlement

programs.

Discretionary time: That portion of time during which

individuals are not engaged in mandatory or maintenance activities (e.g., school, work, sleeping, eating).

Disease: Any deviation from or interruption of the normal

structure of function of any part, organ, or system (or

combination thereof) of the body that is manifested by

a characteristic set of symptoms and signs and whose

etiology, pathology, and prognosis may be known or

unknown.

Domestic discretionary spending: As defined by the

Budget Enforcement Act of 1990 (Title XIII of

OBRA-90 [Public Law 101-508]), discretionary spending that is related to domestic programs (i.e., not to the

military or to assist foreign governments).

Dropout rate: School dropout rates can be defined in

several ways. As defined in this Volume, the dropout

rate is the status dropout rate, or the proportion of a

particular group of individuals (usually an age cohort)

who are not enrolled in school and have not finished

high school at a particular point in time. Compare

graduation rate.

Dysmenorrhea: Difficult and painful menstruation.

Early adolescence: A period encompassing the profound

physical and social changes that occur with puberty, as

maturation begins and social interactions become

increasingly focused on sex (e. g., on members of the

opposite sex). Typically takes place from ages 10

through 14. Compare middle adolescence, late adolescence, younger adolescents, older adolescents.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program: A State and federally

funded, State-administered program under Medicaid

that is intended to provide preventive screening exams

and followup services for illnesses, abnormalities, and

treatable conditions to Medicaid-eligible children under

age 21.

Early intervention: Treatment services delivered before

a problem becomes serious and/or chronic.

Education for All Handicapped Children Act: The

Education for All Handicapped Children Act (Public

Law 94-142) mandates that all physically and mentally

handicapped children be provided a free, appropriate

education and the ‘‘related services’ necessary to

obtain an education. The Federal Government provides a small amount of grant money to States to help

them implement this law.

Educational neglect: As defined by DHHS’s National

Center on Child Abuse and Neglect, educational

neglect can take several forms: permitted chronic

truancy, failure to enroll a school-aged child in school,

causing the child to miss school for nonlegitimate

reasons, and inattention to special educational need

(e.g., refusal to allow or failure to obtain recommended

remedial educational services).

Educationally based preventive interventions: Preventive interventions that rely primarily on educating the

target group. See health education. Compare health

protection and preventive strategies.

Educationally disadvantaged: Having difficulties in

1 earning not related to sheer exertion of effort (although motivational difficulties can also prove a

disadvantage).

Effectiveness: Same as efficacy (see below) except that it

refers to ‘‘. . average or actual conditions of use.

Efficacy: The probability of benefit to individuals in a

defined population from a health care technology

applied for a given health problem under ideal

conditions of use.

Emotional abuse: As defined by DHHS’s National

Center on Child Abuse and Neglect, emotional abuse

takes three different forms: close confinement, such as

tying or binding, or other tortuous restriction of

movement; verbal or emotional assault (e.g., habitual

patterns of belittling, denigrating, or scapegoating);

and other overtly punitive, exploitative, or abusive

treatment other than those specified under other forms

of abuse (e.g., deliberate withholding of food).

Emotional neglect: As defined by DHHS’s National

Center on Child Abuse and Neglect, emotional neglect

can take several forms: inadequate nurturance and

affection; chronic or extreme spouse abuse in the

child’s presence; encouragement or permitting of drug

or alcohol use by the child; permitting other maladaptive behavior; refusal of recommended, needed, and

available psychological care; delay in psychological

care; and other emotional neglect (e.g., other inattention to the child’s developmental/emotional needs not

classifiable under any of the above forms of emotional

neglect, such as inappropriate application of expectations or restrictions).

Emotional problems: The mental health problems exhibited in the form of emotional distress (e.g., anxiety

and depressive disorders); may include subjective

distress. Compare behavioral problems, physical problems.

Employer mandate: A requirement imposed by the

Federal Government on the States that requires employers to offer group health insurance policies and

pay a significant amount of the premiums for all

employees who work more than a specified number of

hours per week.

Empowerment: Empowerment approaches take as a

given that individuals, not just professionals, have a set

of competencies, that these competencies are useful in

the design and management of services, and, further,

that those competencies can be even more fully

developed by giving individuals additional opportuni-
Appendix D—Glossary of Abbreviations and Terms . I-167

ties to control their own lives. Empowerment is

sometimes viewed as a health promotion strategy.

Entitlement programs: Programs that provide benefits

paid out automatically to all who qualify unless there

is a change in underlying law (examples include

Federal employee retirement benefits, Medicare, Medicaid, unemployment compensation, Aid to Families

With Dependent Children).

Epidemiological studies: Studies concerned with the

relationships of various factors determining the frequency and distribution of specific diseases in a human

community.

Ethnicity: A term used to indicate national origin (e.g.,

Hispanic). Most Census and health status information

is available for individuals of Hispanic origin. Compare race.

Exploratory behavior: Behavior engaged in with the

goal of exploring and learning about one’s environment. May involve risk-taking.

Family counseling: Counseling provided to an entire

family rather than solely to an individual.

Family planning: A range of services intended to help

individuals plan when to have children, from counseling concerning the advisability of initiating sexual

intercourse to the provision of contraceptive methods.

See contraception.

Family planning programs authorized by Title X of

the Public Health Service Act: Title X, established by

the Family Planning Services and Population Research

Act of 1970, funds public or private nonprofit entities

that operate voluntary family planning projects; funds

training for personnel to improve the delivery of

family planning services; promotes service delivery

improvement through research; and develops and

disseminates information on family planning. Contraceptives may be distributed without parental consent

or notification, but the use of Title X funds for abortion

as a method of family planning has been prohibited by

statute and regulations. Low-income individuals are

targeted as a priority group for receiving services.

Although projects funded by Title X do not focus

exclusively on adolescents, they are required to offer

a broad range of family planning services to all who

want them, including adolescents.

FamiIy structure: Used to describe whether a family

consists of children and a single parent, two parents

living with their biological children), children living

with a biological parent and a stepparent.

Firearm: A weapon from which a shot is discharged by

gunpowder. The term firearm is usually used only of

small arms. The term firearms includes guns (defined

as portable firearms).

Fitness: Usually defined as cardiorespiratory or aerobic

fitness, but may also include muscle strength, muscle

endurance, flexibility, and low body fat.

Flexible worktime: Structure of individual work schedules so that they adapt to new, different, or changing

requirements (e.g., of parents).

Fluoridation: The addition of a minute quantity of a

fluoride (usually one part per million of fluoride ion)

to drinking water supplies in order to protect growing

children against dental caries. Fluoride can also be

applied topically (in toothpaste and rinses).

Free clinic: Typically freestanding community-based

health services centers that developed in the late 1960s

and early 1970s largely in response to the needs of

substance-abusing youth, many of whom were alienated from society at large and were unable or unwilling

to receive medical care from traditional sources. Free

clinics do not set eligibility requirements or charge fees

for services provided. In general, free clinic services

are provided by volunteers, with agency activities

coordinated by a core of paid staff.

Freestanding (comprehensive) health services centers

(for adolescents): Those centers not located within a

school, health maintenance organization, hospital, or

other facility.

Gonorrhea: A sexually transmitted disease caused by the

bacterial agent Neisseria gonorrhoeae. Gonorrhea can

lead to infertility, premature delivery, acute arthritis,

and disseminated gonococcal infection.

Graduation rate: Graduation rates are calculated by

dividing the number of high school graduates by the

ninth grade enrollment 4 years earlier. Graduation rates

by State are calculated by the U.S. Department of

Education for public schools only because data on

private high school graduates are not available by

State. Compare dropout rate.

(gynecology: The study of diseases peculiar to women,

that is, disorders of the ovaries, fallopian tubes, uterus,

vagina, and vulva, but not including disorders of the

breast.

Hallucinogens: A group of heterogeneous compounds

inducing heightened awareness of sensory input, often

accompanied by an enhanced sense of clarity, and 10SS

of boundaries. Also known as psychedelics.

Health: Most broadly, a state of optimal physical, mental,

and social well-being, and not merely the absence of

disease and infirmity. See adolescent health.

Health education: Activities aimed at influencing behavior in such a way as it is hoped will assist in the

promotion of health and the prevention of disease.

Health maintenance organization (HMO): A health

care organization that, in return for prospective per

capita (cavitation) payments, acts as both insurer and

provider of comprehensive but specified health care

services. A defined set of physicians (and, often, other

health care providers such as physician assistants and

nurse midwives) provide services to a voluntarily

enrolled population. Prepaid group practices and
I-168 ● Adolescent Health—Volume I

individual practice associations, as well as ‘‘staff

models, ” are types of HMOs.

Health outcome: A measure of the effectiveness o f

preventive or treatment health services, typically in

terms of patient health status, but sometimes in terms

of patient satisfaction. Attributing changes in outcomes to health services requires distinguishing the

effects of care from the effects of the many other

factors that influence patients’ health and satisfaction.

Health promotion: Most broadly, a philosophy of health

or a set of activities that takes as its aim the promotion

of health, not just the prevention of disease. Sometimes

narrowly defined as the set of prevention efforts aimed

at changing individual behavior; compare health

education, health protection, and preventive services,

Health protection: Strategies for health promotion and

disease prevention related to environmental or regulatory measures that confer protection on large population groups.

Health services system: Traditionally, the aggregation of

diagnostic and treatment services delivered by health

care professionals, including physicians, physician

assistants, nurses, nurse-practitioners, psychologists,

and health educators.

Health status goals (of the report "Healthy People

2000”): Goals defined in terms of a reduction in death,

disease, or disability (e.g., “Reduce deaths among

youth aged 15 through 24 caused by motor vehicle

crashes to no more than 33 per 100,000 people”

[Healthy People Objective No. 9.3b]).

Heroin: An addictive psychoactive substance derived

from opium.

Hispanics: Persons who identify themselves as of Hispanic origin, or, less typically, individuals with Hispanic surnames identified by others (e.g., health care

providers identifying patients in surveys) as of Hispanic origin. Hispanics can be those whose families

have emigrated directly from Spain, or from Cuba,

Central or South America. Persons of Hispanic origin

can be of any race (white, black American Indian);

most have been found to be white.

Home-based (mental health) services: Crisis-oriented

services, provided on an outreach basis to work

intensively with children and families in their homes.

Considered the extreme on the dimensions of timeliness, accessibility, and intensity.

Hopelessness: The state of being without one’s own

home, either on one’s own, with one’s family, living on

the street or in a shelter or other temporary situation

(e.g,, with relatives or friends). See runaway and

thrownaway.

Hormone: A chemical substance that is released into the

circulatory system by a gland that has a specific

regulatory effect on another organ; functions regulated

include metabolism, growth, and the development of

secondary sex characteristics (e.g., breasts, facial hair).

Human immunodeficiency virus (HIV): The virus that

causes AIDS.

Illicit drug: As used in this Report, any drug that is illegal

for use by persons of any age.

Incidence: In health epidemiology, the measure of the

number of new cases of a particular disease or

condition occurring in a population during a given

period of time. The definition of incidence differs

when used in juvenile justice statistics (see Glossary,

vol. II).

Indian: In this Report, refers to Native Americans in the

continental United States, and Indians, Aleuts, and

Eskimos in Alaska.

Indian tribes: Any Indian tribe, band, nation, group,

Pueblo, rancheria, or community, including any Alaska

Native village, group, or regional or village corporation. A tribe may be federally recognized, Staterecognized, or self-recognized and/or federally terminated. In the context of the Federal-Indian relationship,

tribes must be federally recognized in order to be

eligible for the special programs and services provided

by the United States to Indians because of their status

as Indians. See Indian.

Informed consent: A person’s agreement to allow

something to happen (e.g., a medical procedure) that is

based on a full disclosure of facts needed to make the

decision intelligently. Informed consent is also the

name for a general principle of law that a physician has

a duty to disclose information about the risks of a

proposed treatment to a patient so that the patient may

intelligently exercise his or her judgment about

whether to undergo that treatment.

Inpatient care: Care that includes an overnight stay in a

medical facility.

Interdisciplinary: An approach to training of health care

professionals and delivery of services that uses the

skills of professionals from multiple relevant disciplines (e.g., medicine, nursing, psychology, social

work, health education) with an emphasis on those

professionals working together to deliver services to

adolescents, optimally in a model that does not follow

traditional hierarchies.

Internal medicine: Internal medicine in the United States

differs from general and family practice mainly in not

providing extensive training for pediatric and obstetric

care and in providing more experience with severe and

complex illness. General internal medicine differs

from the subspecialties that have developed out of

internal medicine (e.g., cardiology, oncology, hematology) by offering primary care, including first

contact care and referrals to subspecialists when

warranted.

Internist: A practitioner of internal medicine.

Intravenous: Injected into or delivered through a needle

into a vein.
Appendix D--Glossary of Abbreviations and Terms . I-169

Juvenile justice facility: Includes: 1) juvenile correctional facilities (facilities that hold juveniles after

adjudication and are for the purpose of long-term

commitment or placement for supervision and treatment); and 2) juvenile detention facilities (facilities

that are usually called juvenile detention centers or

juvenile halls, and hold juveniles pending adjudication

or after adjudication and awaiting disposition or

placement). Both juvenile correctional and juvenile

detention facilities can be public (i.e., under the direct

administration and operational control of a State or

local government and staffed by governmental employees) or private (i.e., either profitmaking or nonprofit and subject to governmental licensing but under

the direct administration and operational control of

private enterprise; private facilities may receive substantial public funding in addition to support from

private sources).

Juvenile justice system: The juvenile justice system

includes law enforcement officers and others who refer

delinquent and maltreated juveniles to the courts,

juvenile courts which apply sanctions for delinquent

offenses and oversee the execution of child protective

services, juvenile detention and correctional facilities,

and, less frequently, agencies that provide protective

servicea and care (e.g., foster care) for juvenile victims

of abuse and neglect. The latter agencies intersect with

the child welfare or social services system. See

delinquent behavior, juvenile justice facilities.

Late adolescence: Occurs for those individual, typically

ages 18 to the mid-20s, who, because of educational

goals or other social factors, delay their entry into adult

roles. Compare early adolescence, middle adoles -

cence, younger adolescents, and older adolescents

Legal access: In this Report, used to refer to aspects of

access that have to do with consent and confidentiality.

Leukemia: Cancers of the blood-forming organs, characterized by abnormal proliferation and development of

leukocytes (white blood cells) and their precursors in

the blood and bone marrow.

Life-skills training: The formal teaching of the requisite

skills for surviving, living with others, and succeeding

in a complex society. Life-skills training interventions

emphasize the teaching of social competence, cognitive skills, and decisionmaking skills.

Limitation (in a Iife activity): As defined by the DHHS

National Center for Health Statistics for the National

Health lnterview Survey, refers to what a person is

generally capable of and involved in doing (e.g.. for

those ages 5 to 17 years of age. attending school; for

those under age 5, ordinary play; for those ages 18 to

69, either working for pay or keeping house). Compare

restriction of activity,

Low income: L,iving in-a family that is poor” or near-poor.”

Mainstream health service: Inpatient or outpatient care

in acute care hospitals and ambulatory care in private

office-based physicians’ offices.

Major activity: In national health interview surveys such

as DHHS National Health Interview Survey, persons

are classified in terms of the major activity usually

associated with the particular age group; attending

school is considered the major activity for the age

group 5 to 17. Persons are not classified as having a

limitation in a major activity unless one or more

chronic conditions is reported as the cause of the

activity limitation.

Maltreatment: Physical, emotional, or educational neglect, or physical, emotional or sexual abuse, most

often perpetrated by a family member.

Marijuana: A mild sedative-hypnotic agent, whose

mechanism of action is unknown.

Maternal and child health (MCH) services block grant

program: A Federal block grant program authorized

under Title V of the Social Security Act, that supports

the provisions of health services to mothers and

children, especially those with low income or living in

areas with limited availability of health services. Funds

are provided to States, which in turn may provide them

to local health departments. Created by the Omnibus

Budget Reconciliation Act of 1981, the MCH block

grant consolidated several categorical grant programs

into one block grant. The MCH block grant is

administered by the Bureau of Maternal and Child

Health in the Health Resources and Services Administration in DHHS.

Medicaid: A federally aided, State-administered program

that provides medical assistance for low-income people meeting specific income and family structure

requirements.

Menstruation: The periodic physiological discharge of

blood and mucous membrane from the uterus, recurring at approximately 4-week intervals throughout the

reproductive period of the human female (i. e., from

puberty to menopause).

Mental disorders: See diagnosable mental disorders,

Mental health problems: See diagnosable mental disorders and subjective distress.

Mental health promotion: A broad range of efforts that

seek to foster a healthy mental equilibrium and

maintain emotional stability. See health promotion

and compare prevention.

Mental health services: Care for the treatment of mental

health problems, third-party payment for which is

usually limited to diagnosable mental disorders, and

not available for subjective distress without an accompanying diagnosable mental disorder.

Mental retardation: ,4 term used for mental subnormality (i. e., a deficiency of intellectual function).

Mentoring: The practice of acting over time as a guide,

tutor or coach, and sometimes as an advocate for

another, typically not biologically related, person.
I-170 ● Adolescent Health—Volume I

Middle adolescence: Typically, a time of increasing

independence. Generally takes place during the period

from ages 15 through 17. For those adolescents who do

not go on to (and remain in) college, age 17 or

completion of high school marks the end of adolescence, in social terms. Compare early adolescence,

late adolescence, younger adolescents, older adolescents.

Minor: A person who has not reached the age of majority,

either age 18 or 19, depending on the State. Currently,

the age of majority is set at age 18 in every State but

Alaska, Nebraska, and Wyoming, where the age is 19.

Minor offenses: Federal Bureau of Investigation Part II

offenses, which include drug abuse violations, weapons violations, assaults without weapons, disorderly

conduct, involvement with stolen property, driving

under the influence of alcohol or other drugs, and

status offenses.

Morbidity: The condition of being diseased or otherwise

afflicted with an unhealthful condition. See also new

morbidities.

Multiservicc center: See comprehensive services for

adolescents.

Murder and nonnegligent manslaughter: The willful

(nonnegligent) killing of one human being by another.

Deaths caused by negligence, attempts to kill, assaults

to kill, suicides, accidental deaths, and justifiable

homicides, are excluded. Justifiable homicides are

limited to: 1) the killing of a felon by a law

enforcement officer in the line of duty, and 2) the

killing of a felon by a private citizen.

National Health interview Survey: A continuing nationwide sample survey in which data are collected

through personal household interviews. Information is

obtained on personal and demographic characteristics,

illnesses, injuries, impairments, chronic conditions,

utilization of health resources, and other health topics.

For individuals under age 17, information is collected

from a proxy respondent, typically a parent or guardian. The survey is conducted by the National Center for

Health Statistics in DHHS,

National Survey of Family Growth: An interview

survey, conducted by the National Center for Health

Statistics in DHHS, of a sample of women ages 15 to

44 living in households. The purpose of the survey is

to provide national data on the demographic and social

factors associated with childbearing, adoption, and

maternal and child health. These factors include sexual

activity, marriage, unmarried cohabitation, divorce

and remarriage, contraception and sterilization, infertility, breastfeeding, pregnancy loss, low birthweight,

and use of medical care for family planning, infertility,

and prenatal care. Four ‘‘cycles’ of the survey have

been conducted, the latest in 1988.

Near-poor: Being in a family with an income between

100 percent and 150 percent of the official Federal

poverty level. The Federal poverty level for a family of

three was $10,560 in January 1990.

New morbidities: Illnesses and conditions caused by

social and behavioral (rather than organismic) factors

(e.g., outcomes of sex, drugs, and violence).

Nonnegligent manslaughter: See murder and nonnegligent manslaughter.

obesity: Can be defined in different ways: 1) body mass

index (BMI) weight in kilograms divided by height in

meters squared [m2

]) greater than or equal to the 95th

percentile of a similar population group (usually by

age); or 2) 20 percent or more over ‘‘normal’ weight.

More serious than overweigh.

older adolescents: As defined in most DHHS National

Center for Health Statistics data analyses, adolescents

ages 15 to 19.

“one-stop shopping”: A setting for health care services

that delivers an entire set of comprehensive health

(and, often, related) services. Currently an ideal rather

than an actuality.

outcome: See health outcome.

outpatient care: Care that is provided in a hospital, other

medical facility, or other setting that does not include

an overnight stay. Sometimes limited to care provided

in a hospital setting that does not involve an overnight

stay. Ambulatory care is the broader category, and

includes outpatient care provided in a hospital setting.

Outpatient care is often used as a synonym for

ambulatory care (e.g., when referring to mental health

services).

overweight: Can be defined as body mass index (BMI)

(weight in kilograms divided by height in meters

squared [m2

]) greater than or equal to the 85th

percentile of a similar group. Compare obesity.

Parental consent requirement (applicable to health

care of minors): As used in this Report, a legal

requirement, grounded in common law, that a parent or

other guardian of a minor child must give prior consent

to the delivery of medical or surgical care to that child.

Courts and legislatures have carved out a variety of

exceptions to this requirement and have sometimes

replaced the parental consent requirement with a

parental notification requirement.

Parental notification requirement (applicable to

health care of minors): A legal requirement that the

parents of minors be notified of the decisions of their

minor children to obtain health services. Compare

parental consent requirement.

Parental support (programs): Preventive interventions

that better enable parents to perform any or all of the

following functions in relation to their children (including adolescent children): 1) basic needs (e.g., food,

shelter, education); 2) protection (e.g., of the psychological, spiritual, and cultural integrity of their children

from threats from the natural and social environments);
.- ——

Appendix D-Glossary of Abbreviations and Terms . I-171

3) guidance (in all aspects of the child’s environments;

and 4) advocacy.

Partial hospitalization: See day treatment.

People of color: Individuals who are nonwhite (i.e.,

typically, not of the Caucasian race).

Periodontal: Having to do with the area surrounding the

teeth, including the gums, the bony layers of the teeth

within the gums (cementum), the periodontal membranes, and alveolar (jaw) bone.

Physical (as opposed to mental): Of or related to the

body, and having material existence. See physiological.

Physical abuse: Physical violence, including kicking,

biting, hitting with one’s fist, beating, burning or

scalding, and using a weapon.

Physical neglect: As defined by DHHS’s National Center

on Child Abuse and Neglect, physical neglect can take

seven forms: refusal to provide health care for physical

problems, as recommended by a competent health care

professional; delay in providing health care for a

serious physical problem; desertion of a child without

arranging for reasonable care and supervision (abandonment); other blatant refusals of custody, such as

permanent or indefinite expulsion of a child from the

home; other custody issues, such as chronically and

repeatedly leaving a child with others for days or

weeks at a time; inadequate supervision; and other

physical neglect, such as conspicuous inattention to

avoidable hazards in the home.

Physical problems: See physical and physiology.

PhJ’biological: Having to do with organs, tissues, and

cells, and the physical and chemical phenomena

related to organs, tissues, and cells.

Poor: Being in a family with an income below 100

percent of the Federal poverty level. The Federal

poverty level for a family of three was $10,560 in

January 1990. Compare near-poor.

Postsecondary education: Education that takes place

beyond the high school (12th grade) level.

Poverty level: See poor.

Pregnancy rate: The number of pregnancies per 1,000

population.

Prenatal care: Medical services related to fetal, infant,

and maternal health, delivered from time of conception

to labor.

Prevalence: A measure of the number of individuals in a

given population who have a specific disease or other

condition at a designated time (or during a particular

period). Point prevalence-the proportion of individuals in a population who have a given a condition,

which is measured at a particular point in time.

Lifetime prevalence--a measure of individuals considered at a point in time who have ever had an illness

or condition which is under study.

Preventive services: Strategies for health promotion or

disease prevention that include counseling, screening,

immunization, or chemoprophylactic interventions for

individuals in clinical settings.

Primary care: Optimally, primary care includes the

following elements: first contact care, comprehensive

care, coordinated or integrated care, and care that is

longitudinal over time rather than episodic. First

contact care is the extent to which a patient contacts the

source of care whenever he or she perceived a new

need for care. Coordination of care entails a health care

provider’s ability to provide for continuity of information from visits to other providers (e.g., specialists and

emergency facilities) as well as from earlier visits to

him or herself. Longitudinality of care is the extent to

which a provider serves as a source of care over time

regardless of the presence or absence of a particular

type of problem.

Primary prevention: A category of health and/or related

interventions that aim to eliminate a disease or

disordered state before it can occur. See health

promotion, health protection, preventive services.

Compare secondary prevention.

Proactive: Efforts that attempt to promote health and

prevent the occurrence of health problems by changing

environments rather than merely attempting to change

individual behavior through didactic attempts at persuasion.

Problem behaviors (in adolescence): Those behaviors

that have been deemed socially unacceptable or that

lead to poor health outcomes (e.g., unprotected sexual

intercourse).

Property offenses: According to the Federal Bureau of

Investigation, serious property offenses include burglary, larceny-theft, motor vehicle theft, and arson.

Minor property offenses include involvement with

stolen property. Compare violent offenses.

Protective services: An aspect of social services designed to prevent neglect, abuse, and exploitation of

children by reaching out with social services to

stabilize family life (e.g., by strengthening parental

capacity and ability to provide good child care). The

provision of protective services follows a complaint or

referral, frequently from a source outside the family,

although it may be initiated by an adolescent him or

herself.

Psychiatric hospitalization: Hospitalization in a specialty mental health facility or in a general hospital for

purposes of mental health evaluation or treatment.

Psychoactive substance: A substance that has moodaltering abilities.

Puberty: The period of becoming first capable of

reproducing sexually, marked by maturing of the

genital organs, development of secondary sex characteristics (e.g., breasts, pubic hair), and in humans and

higher primates, the first occurrence of menstruation in

the female.
I-172 ● Adolescent Health—Volume I

Quality of health care: Evaluation of the performance of

health care providers and organizations according to

the degree to which the process of care increases the

probability of outcomes desired by patients and

reduces the probability of undesired outcomes, given

the state of medical knowledge.

Race: Races can be distinguished by usually inherited

physical and physiological characteristics without

regard to language or culture (caucasoids, negroid,

mongoloid). By Census Bureau definition, the term

race is used to distinguish among peoples who are

white (caucasoid), black (negroid), or Asians or Pacific

Islanders or American Indians (mongoloid), See ethnicity, Hispanic, Indian.

Randomized clinical trial: An experiment designed to

test the safety and/or efficacy of an intervention in

which people are randomly allocated to experimental

or control groups, and outcomes are compared.

Related intervention: A preventive or other service that

may enhance health (e.g., social services, vocational

training, educational services, food, housing, mentoring) but is not delivered in what is traditionally

considered the health services system.

Reliability: The extent to which a measurement or result

is obtained consistently.

Reproductive health care: Can include a wide range of

services related to the male or female reproductive

systems, including gynecological treatment services

(i.e., examination and treatment of the female reproductive organs), and preventive services related to the

use of contraception (e.g., counseling, prescribing

contraceptive methods, dispensing contraceptives).

See also prenatal care,

Restricted-activity day: One of the following four types

of days in which a person’s activity is restricted: 1) a

bed day, during which a person stayed in bed more than

half a day because of illness or injury or was in a

hospital as an inpatient; 2) a work-loss day, during

which a currently employed person 18 years of age and

over missed more than half a day from a job or

business; 3) a school-loss day, during which a student

5-to 17-years-old missed more than half a day from the

school in which he or she was currently enrolled; and

4) a cut-down day, during which a person cuts down

for more than half a day on the things he or she usually

does. Work-loss, school-loss, and cut-down days refer

to the short-term effects of illness or injury. Bed days

are a measure of both long- or short-term disability,

however, because a chronically ill bedridden person

and a person with a cold could both report having spent

more than half a day in bed due to an illness. See

restriction of activity.

Restriction of activity: As used in the DHHS National

Center for Health Statistics National Health Interview

Survey, ordinarily refers to a relatively short-term

reduction in a person’s activities below his or her

normal capacity. See restricted-activity day.

Risk reduction goal (of the report “Healthy People

2000”): Defined in terms of prevalence of risks to

health or behaviors known to reduce such risks (e.g.,

‘ ‘Increase use of helmets to at least 80 percent of

motorcyclists and at least 50 percent of bicyclists’

[Healthy People Objective No. 9.13]).

Risk-taking behavior: An activity that may involve a

risk to one’s health. For adolescents especially, risktaking generally carries a negative connotation, but

some risk-taking is essential to the further development of competence, and thus some risk-taking can

have positive health and other benefits.

Robbery: The taking or attempting to take anything of

value from the care, custody, or control of a person or

persons by force or threat of force or violence and/or

by putting the victim in fear.

Rolelessness: The perception by adolescents (and many

learned observers) that adolescents as a socially

defined group do not have clear and useful roles to play

in American society. That is, their function consists

largely of being students and otherwise preparing

themselves for the future, but there are few expectations for them to contribute to society while they are

adolescents.

Runaway: A young person who is away from home at

least overnight without the permission of a parent or

caretaker. Compare homelessness, throwaway, and

street kid.

Rural: As strictly defined by the U.S. Census Bureau,

rural refers to places of 2,500 or fewer residents.

(Census-recognized “places” are either 1) incorporated places such as cities, boroughs, towns, and

villages; or 2) closely settled population centers that

are outside of urbanized areas, do not have corporate

limits, and (unless they are in Alaska and Hawaii) have

a population of at least 1,000. ) The term ‘‘rural’ is

often used to refer to nonmetropolitan statistical areas

(i.e., any area not in a metropolitan statistical area,

which, as defined by the U.S. Office of Management

and Budget, a county or group of counties that includes

either a city of at least 50,000 residents, or an urbanized

area with at least 50,000 people that is itself part of a

county/counties with at least 100,000 total residents).

Safer sex practices: Sexual practices designed to avoid

actual and potential transmission of HIV infection and

other sexually transmitted diseases (e.g., avoiding

exchange of body fluids, use of condoms).

School-linked health centers: Refers to any school

health center for students (and sometimes the family

members of students and/or school dropouts) that

provides a wide range of medical and counseling

services and is located on or near school grounds and

is associated with the school. Compare comprehensive

services for adolescents.
Appendix D—Glossary of Abbreviations and Terms ● /-173

School-loss day: A day in which a student missed more

than half a day from the school in which he or she was

currently enrolled.

Secondary prevention: An intervention that strives to

shorten the course of an illness by early identification

and rapid intervention.

Sedatives: Central nervous system depressants that

produce relief from anxiety, including barbiturates,

metaqualone, and tranquilizers.

Self-insured (health insurance) plan: A self-insured

plan is a health benefit plan in which the financial risk

for providing medical services is assumed by the

employer or sponsor instead of purchasing health

insurance from an insurance company. The employer

or sponsor may continue to contract with an insurance

company or other organization for claims processing

and administrative services, as well as stop-loss

insurance to limit the amount of their liability for

medical claims.

Self-report data: An indication of a survey respondent’s

attitudes, knowledge, or behavior that is reported by

the respondent him or herself.

Serious offenses: Federal Bureau of Investigation Part I

offenses, which include specified violent offenses (i.e.,

murder and nonnegligent manslaughter, forcible rape,

robbery, and aggravated assault) and specified property offenses (i.e., burglary, larceny-theft, motor vehicle theft, and arson).

Sexual abuse: As defined by DHHS’s National Center on

Child Abuse and Neglect, sexual abuse can take three

forms: actual penile penetration; molestation with

genital contact; and other unspecified acts not known

to have involved actual genital contact (e. g., fondling

of breasts or buttocks, exposure), or inadequate or

inappropriate supervision of a child’s voluntary sexual

activities.

Sexual activity rate: As typically used in the literature,

the number of individuals who have ever had sexual

intercourse, per some population base.

Sexually active: As typically used in the literature,

sexually active denotes ever having had sexual intercourse (as opposed to currently being sexually active).

Sexually transmitted disease (STD): An infectious

disease transmitted through sexual intercourse or

genital contact. Formerly (and sometimes, in law)

called venereal disease.

Sickle-cell disease: A lifelong disorder due to an

inherited abnormality of the hemoglobin molecule,

characterized by chronic anemia, a sickle-shaped

deformity of red blood cells, and intermittent occlusions of the the blood vessels.

Sinusitis: Inflammation of one or more of the sinuses that

communicate with the nasal cavity.

Smokeless tobacco: Tobacco that is typically chewed or

held in the mouth rather than smoked. Contains

nicotine, a central nervous system sfimulant.

Social competence: Competence in aspects of interpersonal interaction, including: managing social transactions such as entry into social situations; ability to

maintain satisfying personal and work relationships;

ability to resolve interpersonal problems so that there

is both mutual satisfaction in the encounter and

preservation of valued goals; ability to improvise

effective plans of action in conflicted or disrupted

situations; and ability to reduce stress and contain

anxiety within manageable limits. The mediating

factors affecting social competence that have been

found to be susceptible to life-skills training include

the individual adolescent’s: 1) motivation (i.e., to

acquire knowledge and skills to enhance social competence); 2) knowledge base (i.e., about developmentally

relevant health and social concerns); and 3) social

skills (e.g., communication, empathy, ability to regulate one’s own behavior).

Social environment: The aggregate of social and cultural

conditions that influence the life of an individual or

community. Aspects of the social environment particularly important to adolescents include the adolescents’

families, other adults with whom adolescents come in

contact, schools, workplaces, recreational facilities,

and the media.

Social services: Services provided in order to support the

functioning of individuals or family units, including

those services termed: 1 ) ‘ ‘supportive” or ‘‘protec(i]e

services"; 2) supplementary services (i. e., financial

assistance, home aid services (e. g., homemaker, caretaker, and parent aide services), respite care); and 3)

‘‘substitute’ services (e. g., shelter services, foster

care, adoption).

Social support: Can involve the provision of any or all

of: 1 ) supportive aid, including practical services and

material benefits; 2) personal affirmation, including

feedback that raises self-esteem and strengthens personal identity; and 3) supportive affect, particularly

affection, caring, and nurturance. Compare parental

support programs.

Socioeconomic status: Used in this Report as a synonym

for income levels, typically those of an adolescent’s

family of origin, because adolescents are unlikely to

have their own independent sources of income. See

poor, near-poor.

Status dropout rate: See dropout rare.

Status offenses: Acts that are legal offenses solely

because they are committed by a juvenile, such as

running away from home and truancy.

Stimulants: Psychoactive substances that stimulate the

central nervous system, including amphetamines, caffeine, and heroin,

Street kid: A long-term runaway,, throwaway, o r

otherwise homeless child or adolescent who has

become adept at fending for him or herself “on the

street, usually by illegal activities.
I-174 ● Adolescent Health-Volume I

Subjective distress: Feelings of sadness, hopelessness,

discouragement, boredom, stress, dissatisfaction, or

being worn out or exhausted, that are self-reported by

individuals but are not necessarily symptoms of

diagnosable mental disorders.

Substance: Term used for alcohol, tobacco, and illicit

drugs.

Substance abuse: What constitutes adolescent substance

abuse (any use at all or ‘‘problem’ use) is a matter of

controversy. The DHHS Office of Substance Abuse

Prevention is of the view that any use by adolescents

of psychoactive substances by adolescents should be

considered abuse; the American Psychiatric Association distinguishes between substance use, substance

abuse, and substance dependence, although does not

make distinctions by age. According to the American

Psychiatric Association’s diagnostic manual (DSM-IIIR), substance abuse is characterized by maladaptive

patterns of substance use that have never met the

criteria for dependence for that particular class of

substance, that results in harm to the user, and that the

user continues despite persistent or recurrent adverse

consequences.

Substance dependence: A mental disorder in which a

person has impaired control of psychoactive substance

use and continues use despite adverse consequences. It

is characterized by compulsive behavior and the active

pursuit of a lifestyle that centers around searching for,

obtaining, and using the drug.

Suicide: The taking of one’s own life.

Survival sex: Engaging in sexual intercourse in exchange

for food, shelter, money, or drugs.

Syphilis: A sexually transmitted disease caused by the

bacterial agent Treponema pallidum, resulting in

symptoms including chancre (primary syphilis); skin

rash, malaise, anorexia, nausea (secondary syphilis);

and eventually, central nervous system abnormalities

and other serious problems (tertiary syphilis).

Therapeutic foster care: A type of mental health care

optimally involving the following features: 1) placement of a child with foster parents who have specifically been recruited to work with an emotionally

disturbed child or adolescent; 2) provision of special

training to the foster parents to assist them in working

with the child; 3) placement of only one child in each

special foster home (with occasional exceptions); 4) a

low staff to client ratio, thereby allowing clinical staff

to work very closely with each child, with the foster

parents, and with the biological parents if they are

available; 5) creation of a support system among the

foster parents; and 6) payment of a special stipend to

the foster parents for working with the emotionally

disturbed child or adolescent, and for participating in

the training and other program activities. Regarded as

the least restrictive of residential mental health services,

Therapeutic group care: A type of mental health care

provided in homes which typically serve anywhere

from 5 to 10 children or adolescents, and provide an

array of therapeutic interventions and a therapeutic

environment.

Third-party payment: Payment by a private insurer or

government program to a medical provider for care

given to a patient.

Thrownaway: A child or adolescent who has been told

to leave the household, has been abandoned or

deserted, or who has run away and no effort has been

made to recover him or her.

Title X: See family planning programs authorized by

Title X of the Public Health Service Act.

Tracking: The assigning of students to a particular

curricular track, usually on the basis of estimated

ability.

Tranquilizers: See sedatives.

Traumatic brain injury: Injury to the brain occurring as

the result of impact.

Treatment: Interventions intended to cure or ameliorate

the effects of a disease or condition once the condition

has occurred.

Tribal groups: See Indian tribes.

Unprotected sexual intercourse: Sexual intercourse

without precautions taken to prevent pregnancy or the

transmission of AIDS or sexually transmitted diseases.

Validity: A measure of the extent to which an observed

situation reflects the true situation.

Venereal disease: See sexually transmitted disease.

Violent offenses: According to the Federal Bureau of

Investigation, serious violent offenses include murder

and nonnegligent manslaughter, forcible rape, robbery, and aggravated assault. Minor violent offenses

include assaults without weapons and weapons violations. Compare property offenses.

Waiting mode: The waiting mode of health service

delivery is characterized most strongly by professionals physically remaining within a service system and,

indeed, waiting for clients, generally with chronic

problems, to come to them. The waiting mode is

distinguished from the “seeking mode” wherein

professionals are usually physically operating outside

the service system and seeking to intervene in problems before they become chronic, In practice, it is

acknowledged that waiting/seeking is best thought of

as a continuum, and less as a dichotomy.

“Wraparound services”: A term used to denote a

philosophy or practice of flexibly providing and

funding mental health services that are designed to

meet the unique needs of a particular adolescent, rather

than (or in addition to) providing specified funding for

particular settings or types of services (e.g., hospitals).

The service package is developed by the child or

adolescent’s case manager and is purchased from

vendors; when a service for a given child or adolescent
Appendix D—Glossary of Abbreviations and Terms . I-175

is not available from an existing organization, funds Youth Advisory Panel (OTA’s): The group of 21 young

are used to develop the service (e.g., flying in a people ages 10 through 19 who met with OTA staff, the

consultant to treat a patient with schizophrenia rather OTA Adolescent Health Advisory Panel, and attended

than moving the patient to a hospital in another State).

Younger adolescents: As defined in most studies and

workshops in order to provide the adolescent perspecdata analyses, adolescents ages 10 to 14.

tive on health issues.
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1

1

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